Universal API Implementation Guide
1.1.20 - ci-build
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
{
"resourceType" : "Bundle",
"id" : "88b42c3d-2926-46de-b696-e8713f02f8cb",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-copay-enrollment-bundle"
]
},
"identifier" : {
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "RI",
"display" : "Resource identifier"
}
]
},
"system" : "http://vendor.com/ab",
"value" : "88b42c3d-2926-46de-b696-e8713f02f8cb",
"assigner" : {
"display" : "Alpha Beta"
}
},
"type" : "message",
"timestamp" : "2020-03-11T08:10:13-05:00",
"entry" : [
{
"fullUrl" : "urn:uuid:05621068-0e0b-4bc3-a0d0-d21f9270bcfd",
"resource" : {
"resourceType" : "MessageHeader",
"id" : "05621068-0e0b-4bc3-a0d0-d21f9270bcfd",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-messageheader"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"MessageHeader_05621068-0e0b-4bc3-a0d0-d21f9270bcfd\"> </a><p class=\"res-header-id\"><b>Generated Narrative: MessageHeader 05621068-0e0b-4bc3-a0d0-d21f9270bcfd</b></p><a name=\"05621068-0e0b-4bc3-a0d0-d21f9270bcfd\"> </a><a name=\"hc05621068-0e0b-4bc3-a0d0-d21f9270bcfd\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-messageheader.html\">UAPI MessageHeader</a></p></div><p><b>UAPI MessageHeader Timestamp</b>: 2020-03-11 08:10:13-0500</p><p><b>event</b>: uapi-event-type copay-enrollment: copay-enrollment</p><h3>Destinations</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style=\"display: none\">*</td><td>UAPI-COPAY-ENR-V1.0</td><td><a href=\"https://test-us-e1.apis.roche.com/pharma-cmg-copay-exp-test/v1/enroll\">https://test-us-e1.apis.roche.com/pharma-cmg-copay-exp-test/v1/enroll</a></td></tr></table><p><b>sender</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><h3>Sources</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td style=\"display: none\">*</td><td>Vendor_Tailormed</td><td><a href=\"http://vendor.com/fhir/enrollmentID/ENR-00001\">http://vendor.com/fhir/enrollmentID/ENR-00001</a></td></tr></table><p><b>focus</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-8e055260-dd74-4c89-9ccf-3d2f47135ee0\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p></div>"
},
"extension" : [
{
"url" : "https://fhir.developer.gene.com/StructureDefinition/message-timestamp",
"valueDateTime" : "2020-03-11T08:10:13-05:00"
}
],
"eventCoding" : {
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type",
"code" : "copay-enrollment"
},
"destination" : [
{
"name" : "UAPI-COPAY-ENR-V1.0",
"endpoint" : "https://test-us-e1.apis.roche.com/pharma-cmg-copay-exp-test/v1/enroll"
}
],
"sender" : {
"reference" : "urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2",
"type" : "Organization"
},
"source" : {
"name" : "Vendor_Tailormed",
"endpoint" : "http://vendor.com/fhir/enrollmentID/ENR-00001"
},
"focus" : [
{
"reference" : "urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0",
"type" : "List"
}
]
}
},
{
"fullUrl" : "urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0",
"resource" : {
"resourceType" : "List",
"id" : "8e055260-dd74-4c89-9ccf-3d2f47135ee0",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"List_8e055260-dd74-4c89-9ccf-3d2f47135ee0\"> </a><p class=\"res-header-id\"><b>Generated Narrative: List 8e055260-dd74-4c89-9ccf-3d2f47135ee0</b></p><a name=\"8e055260-dd74-4c89-9ccf-3d2f47135ee0\"> </a><a name=\"hc8e055260-dd74-4c89-9ccf-3d2f47135ee0\"> </a><h2>messageContext</h2><table class=\"clstu\"><tr><td>Mode: Change List </td><td>Status: Current </td></tr><tr><td/></tr></table><table class=\"grid\"><tr style=\"backgound-color: #eeeeee\"><td><b>Items</b></td></tr><tr><td><a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-982e97af-668d-41ef-b9f9-2bbc4a059330\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-cc31cf51-ea4f-4623-bdbb-2ea9e0068a20\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-88b42c3d-2926-46de-b696-e8713f02f8cb.html#urn-uuid-c29782b4-6ffc-494e-85ab-eee27bfd994a\">Bundle: identifier = Resource identifier: 88b42c3d-2926-46de-b696-e8713f02f8cb; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-04afa000-48a5-4fb2-8707-6a43af045868.html#urn-uuid-42b41bdb-1781-49aa-a091-78cdd92129df\">Bundle: identifier = Resource identifier: 6a7dbbed-6c6f-48b0-b32e-0a5d89dc72b2; type = message; timestamp = 2024-04-02 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-d212ac11-903c-4040-a3d7-6b3e1874a311\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-88b42c3d-2926-46de-b696-e8713f02f8cb.html#urn-uuid-72d8daf1-f80f-4e56-bfcb-0558caf74feb\">Bundle: identifier = Resource identifier: 88b42c3d-2926-46de-b696-e8713f02f8cb; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-12ed44e8-fde2-415d-9dcc-8e9117c73d2a\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr></table></div>"
},
"status" : "current",
"mode" : "changes",
"title" : "messageContext",
"entry" : [
{
"item" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
}
},
{
"item" : {
"reference" : "urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2",
"type" : "Organization"
}
},
{
"item" : {
"reference" : "urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f",
"type" : "Organization"
}
},
{
"item" : {
"reference" : "urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330",
"type" : "Organization"
}
},
{
"item" : {
"reference" : "urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20",
"type" : "Practitioner"
}
},
{
"item" : {
"reference" : "urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a",
"type" : "QuestionnaireResponse"
}
},
{
"item" : {
"reference" : "urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df",
"type" : "Coverage"
}
},
{
"item" : {
"reference" : "urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311",
"type" : "Coverage"
}
},
{
"item" : {
"reference" : "urn:uuid:72d8daf1-f80f-4e56-bfcb-0558caf74feb",
"type" : "Task"
}
},
{
"item" : {
"reference" : "urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a",
"type" : "RelatedPerson"
}
}
]
}
},
{
"fullUrl" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"resource" : {
"resourceType" : "Patient",
"id" : "fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-patient"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_fc2e5a72-c363-4616-ae00-4ad25cbcb45c\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient fc2e5a72-c363-4616-ae00-4ad25cbcb45c</b></p><a name=\"fc2e5a72-c363-4616-ae00-4ad25cbcb45c\"> </a><a name=\"hcfc2e5a72-c363-4616-ae00-4ad25cbcb45c\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-patient.html\">UAPI Patient</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Ryan Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 6bcd8467-0473-4836-9128-2e7972f23177\u00a0(use:\u00a0official,\u00a0))</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Ways to contact the Patient\">Contact Detail</td><td colspan=\"3\"><ul><li>ph: 1231231234(Home)</li><li>ph: 1234561234(Mobile)</li><li><a href=\"mailto:bobster83@example.com\">bobster83@example.com</a></li><li>1234 Main St San Francisco CA 94105 US </li></ul></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Language spoken\">Language:</td><td colspan=\"3\"><span title=\"Codes:{urn:ietf:bcp:47 en}\">English</span> (preferred)</td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Patient Links\">Links:</td><td colspan=\"3\"><ul><li>General Practitioner: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-cc31cf51-ea4f-4623-bdbb-2ea9e0068a20\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></li><li>Managing Organization: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></li></ul></td></tr></table></div>"
},
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PI",
"display" : "Patient internal identifier"
}
]
},
"system" : "http://vendor.com/ab",
"value" : "6bcd8467-0473-4836-9128-2e7972f23177",
"assigner" : {
"display" : "AB Vendor"
}
}
],
"name" : [
{
"use" : "official",
"family" : "Michaelson",
"given" : [
"Ryan"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "1231231234",
"use" : "home",
"rank" : 1
},
{
"system" : "phone",
"value" : "1234561234",
"use" : "mobile",
"rank" : 2
},
{
"system" : "email",
"value" : "bobster83@example.com",
"use" : "home",
"rank" : 3
}
],
"gender" : "male",
"birthDate" : "1972-10-29",
"address" : [
{
"line" : [
"1234 Main St"
],
"city" : "San Francisco",
"state" : "CA",
"postalCode" : "94105",
"country" : "US"
}
],
"communication" : [
{
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en",
"display" : "English"
}
]
},
"preferred" : true
}
],
"generalPractitioner" : [
{
"reference" : "urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20"
}
],
"managingOrganization" : {
"reference" : "urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2"
}
}
},
{
"fullUrl" : "urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2",
"resource" : {
"resourceType" : "Organization",
"id" : "be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2</b></p><a name=\"be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\"> </a><a name=\"hcbe7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-organization.html\">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://vendor.com/ab</code>/HOSP-12345\u00a0(use:\u00a0usual,\u00a0), National provider identifier/1922071448\u00a0(use:\u00a0usual,\u00a0)</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}\">Healthcare Provider</span></p><p><b>name</b>: Cleveland Clinic</p><p><b>telecom</b>: ph: 8882704882(Work)</p><p><b>address</b>: 8 Ranoldo Terrace Cherry Hill NJ 08034 US </p><h3>Contacts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td style=\"display: none\">*</td><td>MARISSA CRUZ (Official)</td><td>ph: -unknown-</td></tr></table></div>"
},
"identifier" : [
{
"use" : "usual",
"system" : "http://vendor.com/ab",
"value" : "HOSP-12345",
"assigner" : {
"display" : "AB Vendor"
}
},
{
"use" : "usual",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NPI",
"display" : "National provider identifier"
}
]
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1922071448",
"assigner" : {
"display" : "Cleveland Clinic"
}
}
],
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "prov",
"display" : "Healthcare Provider"
}
]
}
],
"name" : "Cleveland Clinic",
"telecom" : [
{
"system" : "phone",
"value" : "8882704882",
"use" : "work",
"rank" : 1
}
],
"address" : [
{
"line" : [
"8 Ranoldo Terrace"
],
"city" : "Cherry Hill",
"state" : "NJ",
"postalCode" : "08034",
"country" : "US"
}
],
"contact" : [
{
"name" : {
"use" : "official",
"family" : "CRUZ",
"given" : [
"MARISSA"
]
},
"telecom" : [
{
"system" : "phone"
}
]
}
]
}
},
{
"fullUrl" : "urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f",
"resource" : {
"resourceType" : "Organization",
"id" : "d3637025-883d-4678-9e0a-1d243a338f9f",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_d3637025-883d-4678-9e0a-1d243a338f9f\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization d3637025-883d-4678-9e0a-1d243a338f9f</b></p><a name=\"d3637025-883d-4678-9e0a-1d243a338f9f\"> </a><a name=\"hcd3637025-883d-4678-9e0a-1d243a338f9f\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-organization.html\">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://vendor.com/ab</code>/PAY-111\u00a0(use:\u00a0usual,\u00a0)</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}\">Insurance Company</span></p><p><b>name</b>: Kaiser</p><p><b>telecom</b>: ph: 8778472862(Work)</p></div>"
},
"identifier" : [
{
"use" : "usual",
"system" : "http://vendor.com/ab",
"value" : "PAY-111",
"assigner" : {
"display" : "AB Vendor"
}
}
],
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "ins"
}
]
}
],
"name" : "Kaiser",
"telecom" : [
{
"system" : "phone",
"value" : "8778472862",
"use" : "work",
"rank" : 1
}
]
}
},
{
"fullUrl" : "urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330",
"resource" : {
"resourceType" : "Organization",
"id" : "982e97af-668d-41ef-b9f9-2bbc4a059330",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-organization"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_982e97af-668d-41ef-b9f9-2bbc4a059330\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization 982e97af-668d-41ef-b9f9-2bbc4a059330</b></p><a name=\"982e97af-668d-41ef-b9f9-2bbc4a059330\"> </a><a name=\"hc982e97af-668d-41ef-b9f9-2bbc4a059330\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-organization.html\">UAPI Organization</a></p></div><p><b>identifier</b>: <code>http://vendor.com/ab</code>/PAY-145\u00a0(use:\u00a0usual,\u00a0)</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}\">Insurance Company</span></p><p><b>name</b>: CVS Specialty</p><p><b>telecom</b>: ph: -unknown-</p><h3>Contacts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Telecom</b></td></tr><tr><td style=\"display: none\">*</td><td>ph: 8778472862(Work)</td></tr></table></div>"
},
"identifier" : [
{
"use" : "usual",
"system" : "http://vendor.com/ab",
"value" : "PAY-145",
"assigner" : {
"display" : "Ph Vendor"
}
}
],
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/organization-type",
"code" : "ins"
}
]
}
],
"name" : "CVS Specialty",
"telecom" : [
{
"system" : "phone"
}
],
"contact" : [
{
"telecom" : [
{
"system" : "phone",
"value" : "8778472862",
"use" : "work",
"rank" : 1
}
]
}
]
}
},
{
"fullUrl" : "urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20",
"resource" : {
"resourceType" : "Practitioner",
"id" : "cc31cf51-ea4f-4623-bdbb-2ea9e0068a20",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_cc31cf51-ea4f-4623-bdbb-2ea9e0068a20\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner cc31cf51-ea4f-4623-bdbb-2ea9e0068a20</b></p><a name=\"cc31cf51-ea4f-4623-bdbb-2ea9e0068a20\"> </a><a name=\"hccc31cf51-ea4f-4623-bdbb-2ea9e0068a20\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-practitioner.html\">UAPI Practitioner</a></p></div><p><b>UAPI Practitioner Preferred Contact Method</b>: <span title=\"Codes:{https://fhir.developer.gene.com/CodeSystem/prescriber-contact-method work-phone}\">work-phone</span></p><p><b>UAPI Practitioner Shipment Method</b>: <span title=\"Codes:{https://fhir.developer.gene.com/CodeSystem/prescriber-contact-time morning}\">morning</span></p><p><b>identifier</b>: Provider identifier/1922071448\u00a0(use:\u00a0official,\u00a0), National provider identifier/1639285034\u00a0(use:\u00a0official,\u00a0)</p><p><b>name</b>: MARISSA ANNE CRUZ (Official)</p><p><b>telecom</b>: ph: 8882704882(Work), fax: 8882704883(Work), <a href=\"mailto:prescribercopay@example.com\">prescribercopay@example.com</a></p><p><b>address</b>: 8 Ranoldo Terrace Cherry Hill NJ 08034 US </p><h3>Qualifications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Code</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0360 MD}\">Doctor of Medicine</span></td></tr></table></div>"
},
"extension" : [
{
"url" : "https://fhir.developer.gene.com/StructureDefinition/uapi-preferred-contact-method",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://fhir.developer.gene.com/CodeSystem/prescriber-contact-method",
"code" : "work-phone"
}
]
}
},
{
"url" : "https://fhir.developer.gene.com/StructureDefinition/uapi-preferred-contact-time",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://fhir.developer.gene.com/CodeSystem/prescriber-contact-time",
"code" : "morning"
}
]
}
}
],
"identifier" : [
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PRN",
"display" : "Provider identifier"
}
]
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1922071448",
"assigner" : {
"display" : "Cleveland Clinic"
}
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "NPI",
"display" : "National provider identifier"
}
]
},
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1639285034"
}
],
"name" : [
{
"use" : "official",
"family" : "CRUZ",
"given" : [
"MARISSA",
"ANNE"
],
"prefix" : [
"Dr"
],
"suffix" : [
"Junior"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "8882704882",
"use" : "work",
"rank" : 1
},
{
"system" : "fax",
"value" : "8882704883",
"use" : "work",
"rank" : 2
},
{
"system" : "email",
"value" : "prescribercopay@example.com",
"use" : "work",
"rank" : 3
}
],
"address" : [
{
"line" : [
"8 Ranoldo Terrace"
],
"city" : "Cherry Hill",
"state" : "NJ",
"postalCode" : "08034",
"country" : "US"
}
],
"qualification" : [
{
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0360",
"code" : "MD"
}
]
}
}
]
}
},
{
"fullUrl" : "urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a",
"resource" : {
"resourceType" : "QuestionnaireResponse",
"id" : "c29782b4-6ffc-494e-85ab-eee27bfd994a",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"QuestionnaireResponse_c29782b4-6ffc-494e-85ab-eee27bfd994a\"> </a><p class=\"res-header-id\"><b>Generated Narrative: QuestionnaireResponse c29782b4-6ffc-494e-85ab-eee27bfd994a</b></p><a name=\"c29782b4-6ffc-494e-85ab-eee27bfd994a\"> </a><a name=\"hcc29782b4-6ffc-494e-85ab-eee27bfd994a\"> </a><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Definition</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"The type of the item\">Answer</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABAAAAAQCAYAAAAf8/9hAAAABmJLR0QA/wD/AP+gvaeTAAAACXBIWXMAAAsTAAALEwEAmpwYAAAAB3RJTUUH3goXBCwdPqAP0wAAAldJREFUOMuNk0tIlFEYhp9z/vE2jHkhxXA0zJCMitrUQlq4lnSltEqCFhFG2MJFhIvIFpkEWaTQqjaWZRkp0g26URZkTpbaaOJkDqk10szoODP//7XIMUe0elcfnPd9zsfLOYplGrpRwZaqTtw3K7PtGem7Q6FoidbGgqHVy/HRb669R+56zx7eRV1L31JGxYbBtjKK93cxeqfyQHbehkZbUkK20goELEuIzEd+dHS+qz/Y8PTSif0FnGkbiwcAjHaU1+QWOptFiyCLp/LnKptpqIuXHx6rbR26kJcBX3yLgBfnd7CxwJmflpP2wUg0HIAoUUpZBmKzELGWcN8nAr6Gpu7tLU/CkwAaoKTWRSQyt89Q8w6J+oVQkKnBoblH7V0PPvUOvDYXfopE/SJmALsxnVm6LbkotrUtNowMeIrVrBcBpaMmdS0j9df7abpSuy7HWehwJdt1lhVwi/J58U5beXGAF6c3UXLycw1wdFklArBn87xdh0ZsZtArghBdAA3+OEDVubG4UEzP6x1FOWneHh2VDAHBAt80IbdXDcesNoCvs3E5AFyNSU5nbrDPZpcUEQQTFZiEVx+51fxMhhyJEAgvlriadIJZZksRuwBYMOPBbO3hePVVqgEJhFeUuFLhIPkRP6BQLIBrmMenujm/3g4zc398awIe90Zb5A1vREALqneMcYgP/xVQWlG+Ncu5vgwwlaUNx+3799rfe96u9K0JSDXcOzOTJg4B6IgmXfsygc7/Bvg9g9E58/cDVmGIBOP/zT8Bz1zqWqpbXIsd0O9hajXfL6u4BaOS6SeWAAAAAElFTkSuQmCC\" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireResponseRoot\" class=\"hierarchy\"/> c29782b4-6ffc-494e-85ab-eee27bfd994a</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> consent-to-enroll</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Does the patient consent to enroll in the Ocrevus Co-Pay Program?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Yes</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> ocrevus-fda-approved-indications</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is the patient using OCREVUS for the following FDA-approved indications?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><span><span>[not stated] Relapsing-forms-of-multiple-sclerosis-(MS),-to-include-clinically-isolated-syndrome,-relapsing-remitting-disease-and-active-secondary-progressive-disease-or-primary-progressive-forms-of-MS,-in-adults: Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults</span></span></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> 18-years-or-older</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is the patient 18 years of age or older</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Yes</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> commercial-private-insurance</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">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</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Yes</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> federal-state-funded-insurance</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">No</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> have-medicare-card</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Does the patient have a Medicare (red, white and blue) card?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Yes</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> enter-medicare-number</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enter the Medicare number:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">M577788</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> residence-state</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">What state does the patient live in?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">CA</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> receiving-medication-from-gpf</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">No</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> receiving-assistance-from-charitable-organization</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">No</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> agree-to-genentech-privacy-policy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">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 Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus 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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Agree</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> agree-to-copay-program-terms</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">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.\n\nUnder 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.\n\nThe 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.\n\nThe 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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> agree-to-admin-copay-program-terms</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">The Administration 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 and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program.\n\n 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 administration of 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 costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, 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 administration fees 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. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program.\n\n The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment 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.\n\n 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 and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. 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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Agree</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"Item\" class=\"hierarchy\"/> information-correct</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">All information is correct?</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Yes</td></tr>\r\n<tr><td colspan=\"4\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4B/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table></div>"
},
"questionnaire" : "https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234",
"status" : "completed",
"subject" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
},
"item" : [
{
"linkId" : "consent-to-enroll",
"text" : "Does the patient consent to enroll in the Ocrevus Co-Pay Program?",
"answer" : [
{
"valueString" : "Yes"
}
]
},
{
"linkId" : "ocrevus-fda-approved-indications",
"text" : "Is the patient using OCREVUS for the following FDA-approved indications?",
"answer" : [
{
"valueCoding" : {
"code" : "Relapsing-forms-of-multiple-sclerosis-(MS),-to-include-clinically-isolated-syndrome,-relapsing-remitting-disease-and-active-secondary-progressive-disease-or-primary-progressive-forms-of-MS,-in-adults",
"display" : "Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults"
}
}
]
},
{
"linkId" : "18-years-or-older",
"text" : "Is the patient 18 years of age or older",
"answer" : [
{
"valueString" : "Yes"
}
]
},
{
"linkId" : "commercial-private-insurance",
"text" : "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",
"answer" : [
{
"valueString" : "Yes"
}
]
},
{
"linkId" : "federal-state-funded-insurance",
"text" : "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.",
"answer" : [
{
"valueString" : "No"
}
]
},
{
"linkId" : "have-medicare-card",
"text" : "Does the patient have a Medicare (red, white and blue) card?",
"answer" : [
{
"valueString" : "Yes"
}
]
},
{
"linkId" : "enter-medicare-number",
"text" : "Enter the Medicare number:",
"answer" : [
{
"valueString" : "M577788"
}
]
},
{
"linkId" : "residence-state",
"text" : "What state does the patient live in?",
"answer" : [
{
"valueString" : "CA"
}
]
},
{
"linkId" : "receiving-medication-from-gpf",
"text" : "Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?",
"answer" : [
{
"valueString" : "No"
}
]
},
{
"linkId" : "receiving-assistance-from-charitable-organization",
"text" : "Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?",
"answer" : [
{
"valueString" : "No"
}
]
},
{
"linkId" : "agree-to-genentech-privacy-policy",
"text" : "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 Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus 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.",
"answer" : [
{
"valueString" : "Agree"
}
]
},
{
"linkId" : "agree-to-copay-program-terms",
"text" : "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.\n\nUnder 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.\n\nThe 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.\n\nThe 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."
},
{
"linkId" : "agree-to-admin-copay-program-terms",
"text" : "The Administration 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 and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program.\n\n 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 administration of 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 costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, 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 administration fees 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. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program.\n\n The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment 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.\n\n 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 and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. 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.",
"answer" : [
{
"valueString" : "Agree"
}
]
},
{
"linkId" : "information-correct",
"text" : "All information is correct?",
"answer" : [
{
"valueString" : "Yes"
}
]
}
]
}
},
{
"fullUrl" : "urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df",
"resource" : {
"resourceType" : "Coverage",
"id" : "42b41bdb-1781-49aa-a091-78cdd92129df",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_42b41bdb-1781-49aa-a091-78cdd92129df\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage 42b41bdb-1781-49aa-a091-78cdd92129df</b></p><a name=\"42b41bdb-1781-49aa-a091-78cdd92129df\"> </a><a name=\"hc42b41bdb-1781-49aa-a091-78cdd92129df\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-coverage.html\">UAPI Coverage</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><p><b>subscriber</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-12ed44e8-fde2-415d-9dcc-8e9117c73d2a\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>subscriberId</b>: 4353</p><p><b>beneficiary</b>: <a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>period</b>: 2023-01-01 --> (ongoing)</p><p><b>payor</b>: <a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxbin}\">RX BIN</span></p><p><b>value</b>: K12345</p><p><b>name</b>: BIN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}\">RX PCN</span></p><p><b>value</b>: K234516</p><p><b>name</b>: PCN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}\">Group</span></p><p><b>value</b>: KAI2345</p><p><b>name</b>: Group Number</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></p><p><b>value</b>: HMO</p><p><b>name</b>: Plan</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Kaiser</p></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "HIP",
"display" : "health insurance plan policy"
}
]
},
"subscriber" : {
"reference" : "urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a",
"type" : "RelatedPerson"
},
"subscriberId" : "4353",
"beneficiary" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
},
"period" : {
"start" : "2023-01-01"
},
"payor" : [
{
"reference" : "urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f",
"type" : "Organization"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxbin",
"display" : "RX BIN"
}
]
},
"value" : "K12345",
"name" : "BIN"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxpcn",
"display" : "RX PCN"
}
]
},
"value" : "K234516",
"name" : "PCN"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "group",
"display" : "Group"
}
]
},
"value" : "KAI2345",
"name" : "Group Number"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "HMO",
"name" : "Plan"
}
],
"order" : 1,
"network" : "Kaiser"
}
},
{
"fullUrl" : "urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311",
"resource" : {
"resourceType" : "Coverage",
"id" : "d212ac11-903c-4040-a3d7-6b3e1874a311",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_d212ac11-903c-4040-a3d7-6b3e1874a311\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage d212ac11-903c-4040-a3d7-6b3e1874a311</b></p><a name=\"d212ac11-903c-4040-a3d7-6b3e1874a311\"> </a><a name=\"hcd212ac11-903c-4040-a3d7-6b3e1874a311\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-coverage.html\">UAPI Coverage</a></p></div><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode DRUGPOL}\">drug policy</span></p><p><b>subscriber</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-12ed44e8-fde2-415d-9dcc-8e9117c73d2a\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>subscriberId</b>: 4353</p><p><b>beneficiary</b>: <a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>period</b>: 2023-01-01 --> (ongoing)</p><p><b>payor</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-982e97af-668d-41ef-b9f9-2bbc4a059330\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxbin}\">RX BIN</span></p><p><b>value</b>: K3456</p><p><b>name</b>: BIN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}\">RX PCN</span></p><p><b>value</b>: K334455</p><p><b>name</b>: PCN</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class group}\">Group</span></p><p><b>value</b>: KAI2345</p><p><b>name</b>: Group Number</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-class plan}\">Plan</span></p><p><b>value</b>: HMO</p><p><b>name</b>: Plan</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: CVS Specialty</p></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code" : "DRUGPOL",
"display" : "drug policy"
}
]
},
"subscriber" : {
"reference" : "urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a",
"type" : "RelatedPerson"
},
"subscriberId" : "4353",
"beneficiary" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
},
"period" : {
"start" : "2023-01-01"
},
"payor" : [
{
"reference" : "urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330",
"type" : "Organization"
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxbin",
"display" : "RX BIN"
}
]
},
"value" : "K3456",
"name" : "BIN"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxpcn",
"display" : "RX PCN"
}
]
},
"value" : "K334455",
"name" : "PCN"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "group",
"display" : "Group"
}
]
},
"value" : "KAI2345",
"name" : "Group Number"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "plan",
"display" : "Plan"
}
]
},
"value" : "HMO",
"name" : "Plan"
}
],
"order" : 1,
"network" : "CVS Specialty"
}
},
{
"fullUrl" : "urn:uuid:72d8daf1-f80f-4e56-bfcb-0558caf74feb",
"resource" : {
"resourceType" : "Task",
"id" : "72d8daf1-f80f-4e56-bfcb-0558caf74feb",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Task_72d8daf1-f80f-4e56-bfcb-0558caf74feb\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Task 72d8daf1-f80f-4e56-bfcb-0558caf74feb</b></p><a name=\"72d8daf1-f80f-4e56-bfcb-0558caf74feb\"> </a><a name=\"hc72d8daf1-f80f-4e56-bfcb-0558caf74feb\"> </a><p><b>status</b>: Requested</p><p><b>intent</b>: plan</p><p><b>code</b>: <span title=\"Codes:{https://fhir.developer.gene.com/CodeSystem/uapi-sr-type copay}\">Copay</span></p><p><b>for</b>: <a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>authoredOn</b>: 2023-01-23 08:10:13-0500</p><p><b>requester</b>: <a href=\"Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2\">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><blockquote><p><b>input</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type enroll-by-id}\">enroll-by-id</span></p><p><b>value</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-enrollby-id 1}\">Patient</span></p></blockquote><blockquote><p><b>input</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type brandId}\">brandId</span></p><p><b>value</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id 8699576a-3247-429a-9e46-31c00f50f1a0}\">8699576a-3247-429a-9e46-31c00f50f1a0</span></p></blockquote><blockquote><p><b>input</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type brandId}\">brandId</span></p><p><b>value</b>: <span title=\"Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id 2e340749-5d09-4615-b0cf-29cb13d30972}\">2e340749-5d09-4615-b0cf-29cb13d30972</span></p></blockquote></div>"
},
"status" : "requested",
"intent" : "plan",
"code" : {
"coding" : [
{
"system" : "https://fhir.developer.gene.com/CodeSystem/uapi-sr-type",
"code" : "copay"
}
]
},
"for" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
},
"authoredOn" : "2023-01-23T08:10:13-05:00",
"requester" : {
"reference" : "urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2",
"type" : "Organization"
},
"input" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type",
"code" : "enroll-by-id"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-enrollby-id",
"code" : "1",
"display" : "Patient"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type",
"code" : "brandId"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id",
"code" : "8699576a-3247-429a-9e46-31c00f50f1a0"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type",
"code" : "brandId"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id",
"code" : "2e340749-5d09-4615-b0cf-29cb13d30972"
}
]
}
}
]
}
},
{
"fullUrl" : "urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a",
"resource" : {
"resourceType" : "RelatedPerson",
"id" : "12ed44e8-fde2-415d-9dcc-8e9117c73d2a",
"meta" : {
"profile" : [
🔗 "https://fhir.developer.gene.com/StructureDefinition/uapi-relatedPerson"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"RelatedPerson_12ed44e8-fde2-415d-9dcc-8e9117c73d2a\"> </a><p class=\"res-header-id\"><b>Generated Narrative: RelatedPerson 12ed44e8-fde2-415d-9dcc-8e9117c73d2a</b></p><a name=\"12ed44e8-fde2-415d-9dcc-8e9117c73d2a\"> </a><a name=\"hc12ed44e8-fde2-415d-9dcc-8e9117c73d2a\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-uapi-relatedPerson.html\">UAPI RelatedPerson</a></p></div><p><b>patient</b>: <a href=\"Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c\">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-RoleCode SIGOTHR}\">significant other</span></p><p><b>name</b>: Bob Paul Smith (Official)</p><p><b>telecom</b>: ph: 310-462-1234(Mobile)</p><p><b>birthDate</b>: 1972-10-29</p><p><b>address</b>: 8 Ranoldo Terrace Cherry Hill NJ 08034 US </p></div>"
},
"patient" : {
"reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
"type" : "Patient"
},
"relationship" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code" : "SIGOTHR",
"display" : "significant other"
}
]
}
],
"name" : [
{
"use" : "official",
"family" : "Smith",
"given" : [
"Bob Paul"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "310-462-1234",
"use" : "mobile"
}
],
"birthDate" : "1972-10-29",
"address" : [
{
"line" : [
"8 Ranoldo Terrace"
],
"city" : "Cherry Hill",
"state" : "NJ",
"postalCode" : "08034",
"country" : "US"
}
]
}
}
]
}