Message Examples
4 min
note examples are intended for schema illustration purposes only the data supplied in the examples may not be clinically accurate rtpbrequest example note this example includes diagnosis information \<?xml version="1 0" encoding="utf 8"?> \<message rtpbdatatypesversion="pbv13" rtpbtransportversion="pbv13" rtpbtransactiondomain="rtpb" rtpbtransactionversion="pbv13" rtpbstructuresversion="pbv13" rtpbeclversion="pbv13" xsi\ nonamespaceschemalocation="rtpbtransport xsd" rtpbversion="pbv13" xmlns\ xsi="http //www w3 org/2001/xmlschema instance"> \<rtpbheader> \<to> \<primary> \<identification>017010\</identification> \<qualifier>iin\</qualifier> \</primary> \<secondary> \<identification>0215comm\</identification> \<qualifier>pcn\</qualifier> \</secondary> \<tertiary> \<identification>123456789\</identification> \<qualifier>py\</qualifier> \</tertiary> \</to> \<from> \<primary> \<identification>d00000000123597\</identification> \<qualifier>d\</qualifier> \</primary> \</from> \<messageid>somegeneratedehrid\</messageid> \<relatestomessageid>eligibilityidobtainedfromehr\</relatestomessageid> \<senttime>2024 03 12t10 10 02 9587124z\</senttime> \<softwaresendercertificationid>2233445566\</softwaresendercertificationid> \</rtpbheader> \<rtpbbody> \<rtpbrequest> \<patient> \<name> \<lastname>white\</lastname> \<firstname>mary\</firstname> \</name> \<sexandgender> \<administrativegender>f\</administrativegender> \</sexandgender> \<dateofbirth>1935 10 01\</dateofbirth> \<stateprovince>md\</stateprovince> \<postalcode>20850\</postalcode> \<extension name="city" url="http //surescripts com/extensions/rtpbrequest/patient/city"> \<string>annapolis\</string> \</extension> \</patient> \<benefitscoordination> \<pbmmemberid>123456789\</pbmmemberid> \</benefitscoordination> \<requestedproduct> \<product> \<drugcoded> \<ndc>00456140230\</ndc> \</drugcoded> \</product> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c48542\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<dispensedaswrittenproductselectioncode>0\</dispensedaswrittenproductselectioncode> \<diagnosis> \<code>diagnosiscode1\</code> \<qualifier>abf\</qualifier> \</diagnosis> \<diagnosis> \<code>diagnosiscode2\</code> \<qualifier>ld\</qualifier> \</diagnosis> \</requestedproduct> \<prescriber> \<identification> \<npi>2256487127\</npi> \</identification> \<lastname>jones\</lastname> \</prescriber> \<pharmacy> \<identification> \<ncpdpid>0618097\</ncpdpid> \<npi>2123112346\</npi> \</identification> \<businessname>elm street pharmacy\</businessname> \<primarytelephonenumber>3015550120\</primarytelephonenumber> \</pharmacy> \</rtpbrequest> \</rtpbbody> \</message> rtpbresponse example rtpbresponse example \<?xml version="1 0" encoding="utf 8"?> \<message rtpbdatatypesversion="pbv13" rtpbtransportversion="pbv13" rtpbtransactiondomain="rtpb" rtpbtransactionversion="pbv13" rtpbstructuresversion="pbv13" rtpbeclversion="pbv13" rtpbversion="pbv13"> \<rtpbheader> \<to> \<primary> \<identification>d00000000123597\</identification> \<qualifier>d\</qualifier> \</primary> \</to> \<from> \<primary> \<identification>434257\</identification> \<qualifier>iin\</qualifier> \</primary> \<secondary> \<identification>012345\</identification> \<qualifier>pcn\</qualifier> \</secondary> \<tertiary> \<identification>d00000000478396\</identification> \<qualifier>py\</qualifier> \</tertiary> \</from> \<messageid>somegeneratedid\</messageid> \<relatestomessageid>requestidsentfromehr\</relatestomessageid> \<senttime>2024 03 12t10 10 02 9587124z\</senttime> \</rtpbheader> \<rtpbbody> \<rtpbresponse> \<response> \<processed> \<note>success\</note> \</processed> \</response> \<responseproduct> \<product> \<drugcoded> \<ndc>00456401001\</ndc> \</drugcoded> \</product> \<drugdescription>celexa 10mg tablet\</drugdescription> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<pricingandcoverages> \<pharmacy> \<pharmacytype>r\</pharmacytype> \<identification> \<ncpdpid>3412131\</ncpdpid> \<npi>1234567890\</npi> \</identification> \<businessname>unknown\</businessname> \</pharmacy> \<pricingandcoverage> \<pricingandcoverageindicator>r\</pricingandcoverageindicator> \<coveragestatuscode>cc\</coveragestatuscode> \<formularystatus>u\</formularystatus> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<estimatedpatientfinancialresponsibility>703 39\</estimatedpatientfinancialresponsibility> \<patientpaycomponent> \<patientpaycomponentqualifier>01\</patientpaycomponentqualifier> \<patientpaycomponentamount>0 3\</patientpaycomponentamount> \</patientpaycomponent> \<remainingdeductibleamount>40\</remainingdeductibleamount> \<estimatednetplancost>3176 67\</estimatednetplancost> \</pricingandcoverage> \</pricingandcoverages> \<pricingandcoverages> \<pharmacy> \<pharmacytype>m\</pharmacytype> \<identification> \<ncpdpid>2623735\</ncpdpid> \<npi>1234567890\</npi> \</identification> \<businessname>unknown\</businessname> \</pharmacy> \<pricingandcoverage> \<pricingandcoverageindicator>m\</pricingandcoverageindicator> \<coveragestatuscode>cr\</coveragestatuscode> \<formularystatus>u\</formularystatus> \<quantity> \<value>90\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>90\</dayssupply> \<estimatedpatientfinancialresponsibility>766 26\</estimatedpatientfinancialresponsibility> \<remainingdeductibleamount>0\</remainingdeductibleamount> \<estimatednetplancost>3209 05\</estimatednetplancost> \<coveragerestriction> \<coveragerestrictioncode>9g\</coveragerestrictioncode> \</coveragerestriction> \<coveragerestriction> \<coveragerestrictioncode>7x\</coveragerestrictioncode> \</coveragerestriction> \<coveragerestriction> \<coveragerestrictioncode>608\</coveragerestrictioncode> \</coveragerestriction> \<coveragerestriction> \<coveragerestrictioncode>mr\</coveragerestrictioncode> \</coveragerestriction> \<coveragerestriction> \<coveragerestrictioncode>aj\</coveragerestrictioncode> \</coveragerestriction> \</pricingandcoverage> \</pricingandcoverages> \<pricingandcoverages> \<pharmacy> \<pharmacytype>r\</pharmacytype> \<identification> \<ncpdpid>0100949\</ncpdpid> \<npi>1234567890\</npi> \</identification> \<businessname>unknown\</businessname> \</pharmacy> \<pricingandcoverage> \<pricingandcoverageindicator>d\</pricingandcoverageindicator> \<coveragestatuscode>cr\</coveragestatuscode> \<formularystatus>u\</formularystatus> \<quantity> \<value>90\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>90\</dayssupply> \<coveragerestriction> \<coveragerestrictioncode>7x\</coveragerestrictioncode> \</coveragerestriction> \</pricingandcoverage> \</pricingandcoverages> \</responseproduct> \<responsealternativeproduct> \<product> \<drugcoded> \<ndc>00185037101\</ndc> \</drugcoded> \</product> \<drugdescription>firstalternate\</drugdescription> \<pricingandcoverages> \<pharmacy> \<pharmacytype>r\</pharmacytype> \<identification> \<ncpdpid>3412131\</ncpdpid> \<npi>1234567890\</npi> \</identification> \<businessname>unknown\</businessname> \</pharmacy> \<pricingandcoverage> \<pricingandcoverageindicator>r\</pricingandcoverageindicator> \<coveragestatuscode>cc\</coveragestatuscode> \<formularystatus>u\</formularystatus> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<estimatedpatientfinancialresponsibility>3 6\</estimatedpatientfinancialresponsibility> \</pricingandcoverage> \</pricingandcoverages> \</responsealternativeproduct> \<responsealternativeproduct> \<product> \<drugcoded> \<ndc>00378700110\</ndc> \</drugcoded> \</product> \<drugdescription>secondalternate\</drugdescription> \<pricingandcoverages> \<pharmacy> \<pharmacytype>r\</pharmacytype> \<identification> \<ncpdpid>3412131\</ncpdpid> \<npi>1234567890\</npi> \</identification> \<businessname>unknown\</businessname> \</pharmacy> \<pricingandcoverage> \<pricingandcoverageindicator>r\</pricingandcoverageindicator> \<coveragestatuscode>cc\</coveragestatuscode> \<formularystatus>u\</formularystatus> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c28254\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<estimatedpatientfinancialresponsibility>3 6\</estimatedpatientfinancialresponsibility> \</pricingandcoverage> \</pricingandcoverages> \</responsealternativeproduct> \</rtpbresponse> \</rtpbbody> \</message> affiliated pharmacy request example \<?xml version="1 0" encoding="utf 8"?> \<message rtpbdatatypesversion="pbv13" rtpbtransportversion="pbv13" rtpbtransactiondomain="rtpb" rtpbtransactionversion="pbv13" rtpbstructuresversion="pbv13" rtpbeclversion="pbv13" xsi\ nonamespaceschemalocation="rtpbtransport xsd" rtpbversion="pbv13" xmlns\ xsi="http //www w3 org/2001/xmlschema instance"> \<rtpbheader> \<to> \<primary> \<identification>s00000000000005\</identification> \<qualifier>py\</qualifier> \</primary> \<secondary> \<identification>t00000001123020\</identification> \<qualifier>py\</qualifier> \</secondary> \</to> \<from> \<primary> \<identification>d00000000123597\</identification> \<qualifier>d\</qualifier> \</primary> \</from> \<messageid>somegeneratedehrid\</messageid> \<relatestomessageid>eligibilityidobtainedfromehr\</relatestomessageid> \<senttime>2024 03 12t10 10 02 9587124z\</senttime> \<softwaresendercertificationid>2233445566\</softwaresendercertificationid> \</rtpbheader> \<rtpbbody> \<rtpbrequest> \<patient> \<name> \<lastname>white\</lastname> \<firstname>mary\</firstname> \</name> \<sexandgender> \<administrativegender>f\</administrativegender> \</sexandgender> \<dateofbirth>1935 10 01\</dateofbirth> \<stateprovince>md\</stateprovince> \<postalcode>20850\</postalcode> \<extension name="city" url="http //surescripts com/extensions/rtpbrequest/patient/city"> \<string>annapolis\</string> \</extension> \</patient> \<benefitscoordination> \<pbmmemberid>123456789\</pbmmemberid> \</benefitscoordination> \<requestedproduct> \<product> \<drugcoded> \<ndc>00456140230\</ndc> \</drugcoded> \</product> \<quantity> \<value>30\</value> \<codelistqualifier>38\</codelistqualifier> \<quantityunitofmeasure> \<code>c48542\</code> \</quantityunitofmeasure> \</quantity> \<dayssupply>30\</dayssupply> \<dispensedaswrittenproductselectioncode>0\</dispensedaswrittenproductselectioncode> \</requestedproduct> \<prescriber> \<identification> \<npi>2256487127\</npi> \</identification> \<lastname>jones\</lastname> \</prescriber> \<pharmacy> \<identification> \<ncpdpid>0618097\</ncpdpid> \<npi>2123112346\</npi> \</identification> \<businessname>elm street pharmacy\</businessname> \<primarytelephonenumber>3015550120\</primarytelephonenumber> \</pharmacy> \<! partner / secondary pharmacy > \<extension name="secondarypharmacy" url="http //surescripts com/extensions/rtpbrequest/secondarypharmacy"> \<extension name="identification" url="identification"> \<extension name="ncpdpid" url="ncpdpid"> \<string>1375426\</string> \</extension> \<extension name="npi" url="npi"> \<string>2123112346\</string> \</extension> \</extension> \<extension name="businessname" url="businessname"> \<string>red lake band of chippewa indians\</string> \</extension> \<extension name="primarytelephonenumber" url="primarytelephonenumber"> \<string>6122223333\</string> \</extension> \</extension> \</rtpbrequest> \</rtpbbody> \</message>