Universal API Implementation Guide - Local Development build (v1.1.20) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Example Bundle: External - UAPI Copay Card Enrollment REQUEST 3
Profile: UAPI Bundle - Copay Enrollment
Bundle 7c8f5054-015b-4bce-99f5-4160a82a4225 of type message
Entry 1 - fullUrl = urn:uuid:05621068-0e0b-4bc3-a0d0-d21f9270bcfd
Resource MessageHeader:
Profile: UAPI MessageHeader
UAPI MessageHeader Timestamp: 2020-03-11 08:10:13-0500
event: uapi-event-type copay-enrollment: copay-enrollment
Destinations
Name UAPI-COPAY-ENR-V1.0 Sources
Name Vendor_Tailormed
Entry 2 - fullUrl = urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0
Resource List:
messageContext
Mode: Change List Status: Current
Entry 3 - fullUrl = urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c
Resource Patient:
Profile: UAPI Patient
Ryan Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 6bcd8467-0473-4836-9128-2e7972f23177 (use: official, ))
Contact Detail
- ph: 1231231234(Home)
- ph: 1234561234(Mobile)
- bobster83@example.com
- 1234 Main St San Francisco CA 94105 US
Language: English (preferred) Links:
- General Practitioner: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500
- Managing Organization: Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500
Entry 4 - fullUrl = urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/HOSP-12345 (use: usual, ), National provider identifier/1922071448 (use: usual, )type: Healthcare Provider
name: Cleveland Clinic
contact
telecom: ph: 8882704882(Work)
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
contact
name: MARISSA CRUZ (Official)
telecom: ph: -unknown-
Entry 5 - fullUrl = urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/PAY-111 (use: usual, )type: Insurance Company
name: Kaiser
Contacts
Telecom ph: 8778472862(Work)
Entry 6 - fullUrl = urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/PAY-145 (use: usual, )type: Insurance Company
name: CVS Specialty
contact
telecom: ph: -unknown-
contact
telecom: ph: 8778472862(Work)
Entry 7 - fullUrl = urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20
Resource Practitioner:
Profile: UAPI Practitioner
UAPI Practitioner Preferred Contact Method: work-phone
UAPI Practitioner Shipment Method: morning
identifier: Provider identifier/1922071448 (use: official, ), National provider identifier/1639285034 (use: official, )
name: MARISSA ANNE CRUZ (Official)
telecom: ph: 8882704882(Work), fax: 8882704883(Work), prescribercopay@example.com
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
Qualifications
Code Doctor of Medicine
Entry 8 - fullUrl = urn:uuid:984b9cae-45b0-407a-a682-11213a40a12f
Resource QuestionnaireResponse:
LinkID Text Definition Answer 984b9cae-45b0-407a-a682-11213a40a12f
Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/4321 consent-to-enroll
Does the patient consent to enroll in the Genentech Oncology Co-Pay Program? Yes Is the patient using POLIVY™ (polatuzumab vedotin-piiq) for one of the following FDA-approved indications? [not stated] combination: POLIVY is a prescription medicine used with other medicines, bendamustine and a rituximab product, to treat diffuse large B-cell lymphoma in adults who have had at least 2 prior therapies. The conditional approval of POLIVY is based on a type of response rate. There are ongoing studies to establish how well the drug works. Is the patient 18 years of age or older Yes Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace Yes Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE. No Does the patient have a Medicare (red, white and blue) card? No What state does the patient live in? DC Is the patient currently receiving Polivy from the Genentech Patient Foundation? No Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Genentech Oncology Co-pay Program? No The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and benefits, will be shared with Genentech, the sponsor of the program, its partners, and their respective affiliates. In addition, information shared by the pharmacy/physician, such as the date the prescription was filled, the date the medication was administered by the physician (if applicable) and the amount that will be reimbursed by Genentech will also be shared. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Genentech Oncology Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Genentech Oncology Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy. Agree The Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine are not eligible. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the cost associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time. Agree Is the patient on POLIVY in combination with RITUXAN® (rituximab) Yes Does the patient wish to receive Copay benefits for Rituxan as well Yes All information is correct? Yes Do you require a 16-digit virtual card number to process the claim? Yes Documentation for this format
Entry 9 - fullUrl = urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: health insurance plan policy
subscriberId: 4353
period: 2023-01-01 --> (ongoing)
class
type: RX BIN
value: K12345
name: BIN
class
type: RX PCN
value: K234516
name: PCN
class
type: Group
value: KAI2345
name: Group Number
class
type: Plan
value: HMO
name: Plan
order: 1
network: Kaiser
Entry 10 - fullUrl = urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: drug policy
subscriberId: 4353
period: 2023-01-01 --> (ongoing)
class
type: RX BIN
value: K3456
name: BIN
class
type: RX PCN
value: K334455
name: PCN
class
type: Group
value: KAI2345
name: Group Number
class
type: Plan
value: HMO
name: Plan
order: 1
network: CVS Specialty
Entry 11 - fullUrl = urn:uuid:226e6ff9-9b26-4d4e-8e5e-e100770d6f4d
Resource Task:
status: Requested
intent: Plan
code: Copay
authoredOn: 2023-01-23 08:10:13-0500
input
type: enroll-by-id
value: Patient
input
type: brandId
value: 2195a20c-4cd6-47d2-8ff6-f458b89281f4
input
type: brandId
value: e36cda77-1c22-467a-b5fd-18ceddb6b023
Entry 12 - fullUrl = urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a
Resource RelatedPerson:
Profile: UAPI RelatedPerson
relationship: significant other
name: Bob Paul Smith (Official)
telecom: ph: 310-462-1234(Mobile)
birthDate: 1972-10-29
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US