RtpbcResponseClaimResponse

RTPBC Response Using ClaimResponse

activeCARIN RTPBC1.0.0resource58 key elements

This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process. It uses the ClaimResponse's "predetermination" processing mode

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse
ID
rtpbc-response-claimresponse
Type
Base Definition
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
id
S
Unique ClaimResponse Resource Identifier
identifier
S1+
RTPBC Response Identifier
identifier.value
S1+
Unique RTPBC response ID
status
S1+
Response status
type
S
Requested Service Type
type.coding1..1
S1+
type.coding.system1..1
S1+
type.coding.code1..1
S1+
type.coding.display1..1
S1+
use
S
Processing Mode
patient
Reference
S
Response Patient Information
insurer
S
insurer.identifier
S1+
insurer.identifier.value
S1+
Payer ID
request
S1+
Submitter's RTPBC Request ID
request.identifier
S1+
request.identifier.value
S1+
RTPBC Request ID
outcome
S
Processing Outcome
disposition
S
Completed Note
item
S
Requested Product and Pharmacy
:benefitRestriction0..*
Extension
S
Benefit Restriction (Extension)
item.itemSequence
S
Indicates that the information in this .item composite relates to the requested product and pharmacy.
item.noteNumber
S
Determination Note Number
item.adjudication
S
Requested Product and Pharmacy Determination
item.adjudication.category
S
Patient Pay Component
item.adjudication.amount
S1+
Patient Pay Component Amount
item.adjudication.amount.value
S1+
Patient Pay Amount Value
item.adjudication.amount.currency
S1+
Patient Pay Amount Currency
addItem
S
:isAlternative1..1
Extension
S1+
Is Alternative (Extension)
:benefitRestriction0..*
Extension
S
Benefit Restriction (Extension)
addItem.itemSequence
S1+
Associated request Item Sequence
addItem.provider
Reference
S1+
Priced Pharmacy
addItem.provider.reference
S1+
Reference to Priced Pharmacy
addItem.productOrService
S
Product
addItem.productOrService.coding
S1+
addItem.productOrService.coding.system
S1+
addItem.productOrService.coding.code
S1+
addItem.productOrService.coding.display
S1+
Product Description
addItem.quantity
S1+
Priced Quantity
addItem.quantity.value
S1+
Quantity in Billing Units
addItem.quantity.unit
S1+
Billing unit of measure
addItem.noteNumber
S
Determination Note Number
addItem.adjudication
S
Alternative Product and Pharmacy Determination
addItem.adjudication.category
S
Patient Pay Component
addItem.adjudication.amount
S1+
Patient Pay Component Amount
addItem.adjudication.amount.value
S1+
Patient Pay Amount Value
addItem.adjudication.amount.currency
S1+
Patient Pay Amount Currency
processNote
S
Determination Note
processNote.number
S1+
Determination Note Number
processNote.text
S1+
Determination Note Text
error
S
Error Information
error.code
S
Reject Reason
error.code.coding
S1+
error.code.coding.system
S1+
error.code.coding.code
S1+
Reject Code
error.code.coding.display
S1+
error.code.text
S
Reject Message