description: 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
package_name: hl7.fhir.us.carin
derivation: constraint
name: RtpbcResponseClaimResponse
type: ClaimResponse
elements:
  patient:
    short: Response Patient Information
    refers: ['http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient']
    type: Reference
    mustSupport: true
    label: Response Patient Information
    index: 10
  request:
    label: Submitter's RTPBC Request ID
    short: Submitter's RTPBC Request ID
    mustSupport: true
    index: 14
    elements:
      identifier:
        mustSupport: true
        index: 15
        elements:
          value: {label: RTPBC Request ID, short: RTPBC Request ID, mustSupport: true, index: 16}
        required: [value]
    required: [identifier]
  processNote:
    label: Determination Note
    short: Determination Note
    mustSupport: true
    index: 48
    elements:
      number: {label: Determination Note Number, short: Determination Note Number, mustSupport: true, index: 49}
      text: {label: Determination Note Text, short: Determination Note Text, mustSupport: true, index: 50}
    required: [text, number]
  use:
    label: Processing Mode
    short: Processing Mode
    pattern: {type: Code, value: predetermination}
    mustSupport: true
    index: 9
  item:
    label: Requested Product and Pharmacy
    short: Requested Product and Pharmacy
    mustSupport: true
    index: 19
    extensions:
      benefitRestriction: {url: 'http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction', min: 0, isModifier: false, short: Benefit Restriction (Extension), type: Extension, mustSupport: true, index: 20}
    elements:
      extension:
        isModifier: false
        short: Benefit Restriction (Extension)
        type: Extension
        mustSupport: true
        url: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
        index: 20
        slicing:
          slices:
            benefitRestriction:
              match: {}
              schema: {isModifier: false, short: Benefit Restriction (Extension), type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction', index: 20}
              min: 0
      itemSequence: {mustSupport: true, index: 21}
      noteNumber: {label: Determination Note Number, short: Determination Note Number, mustSupport: true, index: 22}
      adjudication:
        label: Requested Product and Pharmacy Determination
        short: Requested Product and Pharmacy Determination
        mustSupport: true
        index: 23
        elements:
          category:
            short: Patient Pay Component
            mustSupport: true
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type'}
            label: Patient Pay Component
            index: 24
          amount:
            label: Patient Pay Component Amount
            short: Patient Pay Component Amount
            mustSupport: true
            index: 25
            elements:
              value: {label: Patient Pay Amount Value, short: Patient Pay Amount Value, mustSupport: true, index: 26}
              currency:
                label: Patient Pay Amount Currency
                short: Patient Pay Amount Currency
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/currencies'}
                mustSupport: true
                index: 27
            required: [currency, value]
        required: [amount]
  type:
    label: Requested Service Type
    short: Requested Service Type
    mustSupport: true
    index: 4
    elements:
      coding:
        mustSupport: true
        index: 5
        elements:
          system:
            pattern: {type: Uri, value: 'http://terminology.hl7.org/CodeSystem/claim-type'}
            mustSupport: true
            index: 6
          code:
            pattern: {type: Code, value: pharmacy}
            mustSupport: true
            index: 7
          display:
            pattern: {type: String, value: Pharmacy}
            mustSupport: true
            index: 8
        required: [display, system, code]
    required: [coding]
  outcome: {label: Processing Outcome, short: Processing Outcome, mustSupport: true, index: 17}
  disposition: {label: Completed Note, short: Completed Note, mustSupport: true, index: 18}
  insurer:
    mustSupport: true
    index: 11
    elements:
      identifier:
        mustSupport: true
        index: 12
        elements:
          value: {label: Payer ID, short: Payer ID, mustSupport: true, index: 13}
        required: [value]
    required: [identifier]
  status:
    pattern: {type: Code, value: active}
    short: Response status
    mustSupport: true
    label: Response status
    index: 3
  id: {label: Unique ClaimResponse Resource Identifier, short: Unique ClaimResponse Resource Identifier, mustSupport: true, index: 0}
  identifier:
    label: RTPBC Response Identifier
    short: RTPBC Response Identifier
    mustSupport: true
    index: 1
    elements:
      value: {label: Unique RTPBC response ID, short: Unique RTPBC response ID, mustSupport: true, index: 2}
    required: [value]
  error:
    label: Error Information
    short: Error Information
    mustSupport: true
    index: 51
    elements:
      code:
        label: Reject Reason
        short: Reject Reason
        binding: {strength: preferred, valueSet: 'http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code'}
        mustSupport: true
        index: 52
        elements:
          coding:
            mustSupport: true
            index: 53
            elements:
              system: {mustSupport: true, index: 54}
              code: {label: Reject Code, short: Reject Code, mustSupport: true, index: 55}
              display: {mustSupport: true, index: 56}
            required: [display, system, code]
          text: {label: Reject Message, short: Reject Message, mustSupport: true, index: 57}
        required: [coding]
  addItem:
    mustSupport: true
    index: 28
    extensions:
      isAlternative: {url: 'http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative', min: 1, max: 1, isModifier: false, short: Is Alternative (Extension), type: Extension, mustSupport: true, index: 29}
      benefitRestriction:
        url: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
        min: 0
        isModifier: false
        short: Benefit Restriction (Extension)
        type: Extension
        mustSupport: true
        base: {max: '*', min: 0, path: DomainResource.extension}
        index: 30
    elements:
      extension:
        isModifier: false
        short: Is Alternative (Extension)
        type: Extension
        mustSupport: true
        url: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
        index: 29
        slicing:
          slices:
            isAlternative:
              match: {}
              schema: {isModifier: false, short: Is Alternative (Extension), type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative', index: 29}
              min: 1
              max: 1
            benefitRestriction:
              match: {}
              schema:
                isModifier: false
                short: Benefit Restriction (Extension)
                type: Extension
                mustSupport: true
                url: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
                base: {max: '*', min: 0, path: DomainResource.extension}
                index: 30
              min: 0
      itemSequence: {label: Associated request Item Sequence, short: Associated request Item Sequence, mustSupport: true, index: 31}
      provider:
        short: Priced Pharmacy
        index: 32
        refers: ['http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization']
        type: Reference
        mustSupport: true
        elements:
          reference: {label: Reference to Priced Pharmacy, short: Reference to Priced Pharmacy, mustSupport: true, index: 33}
        label: Priced Pharmacy
        required: [reference]
      productOrService:
        label: Product
        short: Product
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code'}
        mustSupport: true
        index: 34
        elements:
          coding:
            mustSupport: true
            index: 35
            elements:
              system: {mustSupport: true, index: 36}
              code: {mustSupport: true, index: 37}
              display: {label: Product Description, short: Product Description, mustSupport: true, index: 38}
            required: [display, system, code]
        required: [coding]
      quantity:
        label: Priced Quantity
        short: Priced Quantity
        mustSupport: true
        index: 39
        elements:
          value: {label: Quantity in Billing Units, short: Quantity in Billing Units, mustSupport: true, index: 40}
          unit:
            label: Billing unit of measure
            short: Billing unit of measure
            binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit'}
            mustSupport: true
            index: 41
        required: [value, unit]
      noteNumber: {label: Determination Note Number, short: Determination Note Number, mustSupport: true, index: 42}
      adjudication:
        label: Alternative Product and Pharmacy Determination
        short: Alternative Product and Pharmacy Determination
        mustSupport: true
        index: 43
        elements:
          category:
            short: Patient Pay Component
            mustSupport: true
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type'}
            label: Patient Pay Component
            index: 44
          amount:
            label: Patient Pay Component Amount
            short: Patient Pay Component Amount
            mustSupport: true
            index: 45
            elements:
              value: {label: Patient Pay Amount Value, short: Patient Pay Amount Value, mustSupport: true, index: 46}
              currency:
                label: Patient Pay Amount Currency
                short: Patient Pay Amount Currency
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/currencies'}
                mustSupport: true
                index: 47
            required: [currency, value]
        required: [amount]
    required: [provider, quantity, itemSequence]
package_version: rtpbc-1.0.0
class: profile
kind: resource
url: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse
base: http://hl7.org/fhir/StructureDefinition/ClaimResponse
version: 1.0.0
required: [status, request, identifier]