External - UAPI Copay claim upsert - bundle of claim bundles - Universal API Implementation Guide v1.1.20

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

Example Bundle: External - UAPI Copay claim upsert - bundle of claim bundles

Bundle uapi-bundle-copay-claim-upsert of type collection

Entry 1 - fullUrl = urn:uuid:d1e49065-2e38-45b0-af50-92e225868140

Resource Bundle:

Bundle uapi-bundle-copay-claim-1 of type collection

Entry 1 - fullUrl = urn:uuid:61b950a7-e518-4f69-b8dd-a1729c8f4bd5
Resource ExplanationOfBenefit:

identifier: /123456 (use: usual, )
status: Active
type: institutional
use: Claim
patient: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
created: 2024-06-06 21:01:11+0000
insurer: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
provider: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500
Payees
- Party
* urn:uuid:081d9568-2f85-4211-a84e-224d675b18ef
outcome: complete
supportingInfo
sequence: 1
category: eobdate
value: 2024-06-07
supportingInfo
sequence: 2
category: ndc
value: 50242021501
supportingInfo
sequence: 3
category: claimrequesteddate
value: 2024-06-01
supportingInfo
sequence: 4
category: claimapproveddate
value: 2024-06-03
supportingInfo
sequence: 5
category: jcode
value: J2357
Insurances
- Focal Coverage
* true urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3
item
sequence: 1
productOrService: 96401
serviced: 2024-06-01
adjudication
category: submitted
Amounts
- Value
* 250
adjudication
category: eligible
Amounts
- Value
* 104.16
adjudication
category: paidtoprovider
Amounts
- Value
* 78.12
adjudication
category: copay
Amounts
- Value
* 0
adjudication
category: deductible
Amounts
- Value
* 25
adjudication
category: coinsurance
Amounts
- Value
* 26.04
adjudication
category: patienttotalresponsibility
Amounts
- Value
* 51.04
Adjudications
- Category Reason
* claimstatus approved
total
category: check
Amounts
- Value
* 5.01
total
category: paidbypatient
Amounts
- Value
* 5
total
category: submitted
Amounts
- Value
* 13.11
Payments
- Type Date Identifier
* paid 2024-06-06 http://risrx.com/checknum/123456

Entry 2 - fullUrl = urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a
Resource Patient:

Profile: UAPI Patient
Ryan Tom Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c (use: usual, ))
Contact Detail
ph: 1231231234(Home)
ph: 1234561234(Mobile)
bobster83@example.com
1234 Main St San Francisco CA 94105 US
Language: English (preferred)
Links:
Managing Organization: urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468

Entry 3 - fullUrl = urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1
Resource Practitioner:

Profile: UAPI Practitioner
identifier: Provider number/1922071448 (use: official, ), Tax ID number/00000000 (use: official, ), National provider identifier/1639285034 (use: official, )
name: MARISSA CRUZ (Official)

Entry 4 - fullUrl = urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545
Resource RelatedPerson:

Profile: UAPI RelatedPerson
patient: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500
relationship: significant other
name: Bob Paul Smith (Official)
telecom: ph: 1234567890(Mobile)
birthDate: 1972-10-29

Entry 5 - fullUrl = urn:uuid:5c2e19ac-8227-4de5-a893-069dec07448e
Resource Coverage:

Profile: UAPI Coverage
UAPI Coverage - Card issuance date: 2023-02-26
status: Active
type: Pay
subscriber: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
subscriberId: EYE00044137
beneficiary: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
period: 2023-02-08 --> 2199-12-31
class
type: RX BIN
value: 600426
name: BIN
class
type: RX PCN
value: 54
name: PCN
class
type: Group
value: EC38532005
name: Group Number
class
type: Plan
value: Xolair-Admin
name: Xolair Co Pay program
order: 1
network: Genentech

Entry 2 - fullUrl = urn:uuid:45597178-f243-419e-8af3-462359f89e91

Resource Bundle:

Bundle uapi-bundle-copay-claim-2 of type collection

Entry 1 - fullUrl = urn:uuid:61b950a7-e518-4f69-b8dd-a1729c8f4bd5
Resource ExplanationOfBenefit:

identifier: /123456 (use: usual, )
status: Active
type: institutional
use: Claim
patient: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
created: 2024-06-06 21:01:11+0000
insurer: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
provider: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500
Payees
- Party
* urn:uuid:081d9568-2f85-4211-a84e-224d675b18ef
outcome: complete
supportingInfo
sequence: 1
category: eobdate
value: 2024-06-07
supportingInfo
sequence: 2
category: ndc
value: 50242021501
supportingInfo
sequence: 3
category: claimrequesteddate
value: 2024-06-01
supportingInfo
sequence: 4
category: claimapproveddate
value: 2024-06-03
supportingInfo
sequence: 5
category: jcode
value: J2357
Insurances
- Focal Coverage
* true urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3
item
sequence: 1
productOrService: 96401
serviced: 2024-06-01
adjudication
category: submitted
Amounts
- Value
* 250
adjudication
category: eligible
Amounts
- Value
* 104.16
adjudication
category: paidtoprovider
Amounts
- Value
* 78.12
adjudication
category: copay
Amounts
- Value
* 0
adjudication
category: deductible
Amounts
- Value
* 25
adjudication
category: coinsurance
Amounts
- Value
* 26.04
adjudication
category: patienttotalresponsibility
Amounts
- Value
* 51.04
Adjudications
- Category Reason
* claimstatus approved
total
category: check
Amounts
- Value
* 5.01
total
category: paidbypatient
Amounts
- Value
* 5
total
category: submitted
Amounts
- Value
* 13.11
Payments
- Type Date Identifier
* paid 2024-06-06 http://risrx.com/checknum/123456

Entry 2 - fullUrl = urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a
Resource Patient:

Profile: UAPI Patient
Ryan Tom Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c (use: usual, ))
Contact Detail
ph: 1231231234(Home)
ph: 1234561234(Mobile)
bobster83@example.com
1234 Main St San Francisco CA 94105 US
Language: English (preferred)
Links:
Managing Organization: urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468

Entry 3 - fullUrl = urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1
Resource Practitioner:

Profile: UAPI Practitioner
identifier: Provider number/1922071448 (use: official, ), Tax ID number/00000000 (use: official, ), National provider identifier/1639285034 (use: official, )
name: MARISSA CRUZ (Official)

Entry 4 - fullUrl = urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545
Resource RelatedPerson:

Profile: UAPI RelatedPerson
patient: Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500
relationship: significant other
name: Bob Paul Smith (Official)
telecom: ph: 1234567890(Mobile)
birthDate: 1972-10-29

Entry 5 - fullUrl = urn:uuid:5c2e19ac-8227-4de5-a893-069dec07448e
Resource Coverage:

Profile: UAPI Coverage
UAPI Coverage - Card issuance date: 2023-02-26
status: Active
type: Pay
subscriber: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
subscriberId: EYE00044137
beneficiary: Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
period: 2023-02-08 --> 2199-12-31
class
type: RX BIN
value: 600426
name: BIN
class
type: RX PCN
value: 54
name: PCN
class
type: Group
value: EC38532005
name: Group Number
class
type: Plan
value: Xolair-Admin
name: Xolair Co Pay program
order: 1
network: Genentech

IG © 2021+ . Package gene.com.fhir.uapi#1.1.20 based on FHIR 4.3.0. Generated 2025-06-25
Links: Table of Contents | QA Report