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
<Bundle xmlns="http://hl7.org/fhir">
<id value="uapi-bundle-copay-claim-upsert"/>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/claimbundleid"/>
<value value="2f057cf1-19d5-425e-bae7-0612026b69cd"/>
</identifier>
<type value="collection"/>
<timestamp value="2024-06-07T08:10:17-05:00"/>
<entry>
<fullUrl value="urn:uuid:d1e49065-2e38-45b0-af50-92e225868140"/>
<resource>
<Bundle>
<id value="uapi-bundle-copay-claim-1"/>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/claimid"/>
<value value="123456"/>
</identifier>
<type value="collection"/>
<timestamp value="2024-06-07T08:10:17-05:00"/>
<entry>
<fullUrl value="urn:uuid:61b950a7-e518-4f69-b8dd-a1729c8f4bd5"/>
<resource>
<ExplanationOfBenefit>
<id value="uapi-eob-copay-claim-1"/>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
</coding>
<coding>
<code value="uc"/>
</coding>
</type>
<system value="http://risrx.com/claimid"/>
<value value="123456"/>
</identifier>
<status value="active"/>
<type>
<coding>
<code value="institutional"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
</patient>
<created value="2024-06-06T21:01:11.230Z"/>
<insurer>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<payee>
<party>
<reference
value="urn:uuid:081d9568-2f85-4211-a84e-224d675b18ef"/>
</party>
</payee>
<outcome value="complete"/>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="eobdate"/>
</coding>
</category>
<valueString value="2024-06-07"/>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="ndc"/>
</coding>
</category>
<valueString value="50242021501"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="claimrequesteddate"/>
</coding>
</category>
<valueString value="2024-06-01"/>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="claimapproveddate"/>
</coding>
</category>
<valueString value="2024-06-03"/>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="jcode"/>
</coding>
</category>
<valueString value="J2357"/>
</supportingInfo>
<insurance>
<focal value="true"/>
<coverage>
<reference
value="urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<productOrService>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes"/>
<code value="96401"/>
</coding>
</productOrService>
<servicedDate value="2024-06-01"/>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="250"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="104.16"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="paidtoprovider"/>
</coding>
</category>
<amount>
<value value="78.12"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="0"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="deductible"/>
</coding>
</category>
<amount>
<value value="25"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="coinsurance"/>
</coding>
</category>
<amount>
<value value="26.04"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="patienttotalresponsibility"/>
</coding>
</category>
<amount>
<value value="51.04"/>
</amount>
</adjudication>
</item>
<adjudication>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/ValueSet/uapi-copay-adjudication-category-discriminator"/>
<code value="claimstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-status"/>
<code value="approved"/>
</coding>
</reason>
</adjudication>
<total>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-payment-type"/>
<code value="check"/>
</coding>
</category>
<amount>
<value value="5.01"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"/>
<code value="paidbypatient"/>
</coding>
</category>
<amount>
<value value="5"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="13.11"/>
</amount>
</total>
<payment>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode"/>
<code value="paid"/>
</coding>
</type>
<date value="2024-06-06"/>
<identifier>
<system value="http://risrx.com/checknum"/>
<value value="123456"/>
</identifier>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<resource>
<Patient>
<id value="3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-patient"/>
</meta>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
</type>
<system value="http://risrx.com/masterpatientcardid"/>
<value value="12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c"/>
<assigner>
<display value="RisRx"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Michaelson"/>
<given value="Ryan"/>
<given value="Tom"/>
</name>
<telecom>
<system value="phone"/>
<value value="1231231234"/>
<use value="home"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="phone"/>
<value value="1234561234"/>
<use value="mobile"/>
<rank value="2"/>
</telecom>
<telecom>
<system value="email"/>
<value value="bobster83@example.com"/>
<use value="home"/>
<rank value="3"/>
</telecom>
<gender value="male"/>
<birthDate value="1972-10-29"/>
<address>
<line value="1234 Main St"/>
<city value="San Francisco"/>
<state value="CA"/>
<postalCode value="94105"/>
<country value="US"/>
</address>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en"/>
<display value="English"/>
</coding>
</language>
<preferred value="true"/>
</communication>
<managingOrganization>
<reference
value="urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468"/>
</managingOrganization>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
<resource>
<Practitioner>
<id value="695d0991-5e03-46df-934a-85a28acd95c1"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"/>
</meta>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PRN"/>
<display value="Provider number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1922071448"/>
<assigner>
<display
value="Centers for Medicare & Medicaid Services"/>
</assigner>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
<display value="Tax ID number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="00000000"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1639285034"/>
</identifier>
<name>
<use value="official"/>
<family value="CRUZ"/>
<given value="MARISSA"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<resource>
<RelatedPerson>
<id value="4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-relatedPerson"/>
</meta>
<patient>
<reference
value="urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c"/>
<type value="Patient"/>
</patient>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="SIGOTHR"/>
<display value="significant other"/>
</coding>
</relationship>
<name>
<use value="official"/>
<family value="Smith"/>
<given value="Bob Paul"/>
</name>
<telecom>
<system value="phone"/>
<value value="1234567890"/>
<use value="mobile"/>
</telecom>
<birthDate value="1972-10-29"/>
</RelatedPerson>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:5c2e19ac-8227-4de5-a893-069dec07448e"/>
<resource>
<Coverage>
<id value="b0574bf9-d016-4af7-a895-269abd739db3"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/IssuedDate">
<valueDate value="2023-02-26"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="pay"/>
<display value="Pay"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</subscriber>
<subscriberId value="EYE00044137"/>
<beneficiary>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2023-02-08"/>
<end value="2199-12-31"/>
</period>
<payor>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxbin"/>
<display value="RX BIN"/>
</coding>
</type>
<value value="600426"/>
<name value="BIN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxpcn"/>
<display value="RX PCN"/>
</coding>
</type>
<value value="54"/>
<name value="PCN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="EC38532005"/>
<name value="Group Number"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Xolair-Admin"/>
<name value="Xolair Co Pay program"/>
</class>
<order value="1"/>
<network value="Genentech"/>
</Coverage>
</resource>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:45597178-f243-419e-8af3-462359f89e91"/>
<resource>
<Bundle>
<id value="uapi-bundle-copay-claim-2"/>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/claimid"/>
<value value="953f66c2-383c-4d8b-a306-2938b1b92f6b"/>
</identifier>
<type value="collection"/>
<timestamp value="2024-06-07T08:10:17-05:00"/>
<entry>
<fullUrl value="urn:uuid:61b950a7-e518-4f69-b8dd-a1729c8f4bd5"/>
<resource>
<ExplanationOfBenefit>
<id value="uapi-eob-copay-claim-1"/>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
</coding>
<coding>
<code value="uc"/>
</coding>
</type>
<system value="http://risrx.com/claimid"/>
<value value="123456"/>
</identifier>
<status value="active"/>
<type>
<coding>
<code value="institutional"/>
</coding>
</type>
<use value="claim"/>
<patient>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
</patient>
<created value="2024-06-06T21:01:11.230Z"/>
<insurer>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<payee>
<party>
<reference
value="urn:uuid:081d9568-2f85-4211-a84e-224d675b18ef"/>
</party>
</payee>
<outcome value="complete"/>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="eobdate"/>
</coding>
</category>
<valueString value="2024-06-07"/>
</supportingInfo>
<supportingInfo>
<sequence value="2"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="ndc"/>
</coding>
</category>
<valueString value="50242021501"/>
</supportingInfo>
<supportingInfo>
<sequence value="3"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="claimrequesteddate"/>
</coding>
</category>
<valueString value="2024-06-01"/>
</supportingInfo>
<supportingInfo>
<sequence value="4"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="claimapproveddate"/>
</coding>
</category>
<valueString value="2024-06-03"/>
</supportingInfo>
<supportingInfo>
<sequence value="5"/>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-supporting-info-category"/>
<code value="jcode"/>
</coding>
</category>
<valueString value="J2357"/>
</supportingInfo>
<insurance>
<focal value="true"/>
<coverage>
<reference
value="urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3"/>
</coverage>
</insurance>
<item>
<sequence value="1"/>
<productOrService>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes"/>
<code value="96401"/>
</coding>
</productOrService>
<servicedDate value="2024-06-01"/>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="250"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="eligible"/>
</coding>
</category>
<amount>
<value value="104.16"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="paidtoprovider"/>
</coding>
</category>
<amount>
<value value="78.12"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="copay"/>
</coding>
</category>
<amount>
<value value="0"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="deductible"/>
</coding>
</category>
<amount>
<value value="25"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="coinsurance"/>
</coding>
</category>
<amount>
<value value="26.04"/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationCategory"/>
<code value="patienttotalresponsibility"/>
</coding>
</category>
<amount>
<value value="51.04"/>
</amount>
</adjudication>
</item>
<adjudication>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/ValueSet/uapi-copay-adjudication-category-discriminator"/>
<code value="claimstatus"/>
</coding>
</category>
<reason>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-claim-status"/>
<code value="approved"/>
</coding>
</reason>
</adjudication>
<total>
<category>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-payment-type"/>
<code value="check"/>
</coding>
</category>
<amount>
<value value="5.01"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"/>
<code value="paidbypatient"/>
</coding>
</category>
<amount>
<value value="5"/>
</amount>
</total>
<total>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication"/>
<code value="submitted"/>
</coding>
</category>
<amount>
<value value="13.11"/>
</amount>
</total>
<payment>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode"/>
<code value="paid"/>
</coding>
</type>
<date value="2024-06-06"/>
<identifier>
<system value="http://risrx.com/checknum"/>
<value value="123456"/>
</identifier>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<resource>
<Patient>
<id value="3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-patient"/>
</meta>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
</type>
<system value="http://risrx.com/masterpatientcardid"/>
<value value="12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c"/>
<assigner>
<display value="RisRx"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Michaelson"/>
<given value="Ryan"/>
<given value="Tom"/>
</name>
<telecom>
<system value="phone"/>
<value value="1231231234"/>
<use value="home"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="phone"/>
<value value="1234561234"/>
<use value="mobile"/>
<rank value="2"/>
</telecom>
<telecom>
<system value="email"/>
<value value="bobster83@example.com"/>
<use value="home"/>
<rank value="3"/>
</telecom>
<gender value="male"/>
<birthDate value="1972-10-29"/>
<address>
<line value="1234 Main St"/>
<city value="San Francisco"/>
<state value="CA"/>
<postalCode value="94105"/>
<country value="US"/>
</address>
<communication>
<language>
<coding>
<system value="urn:ietf:bcp:47"/>
<code value="en"/>
<display value="English"/>
</coding>
</language>
<preferred value="true"/>
</communication>
<managingOrganization>
<reference
value="urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468"/>
</managingOrganization>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
<resource>
<Practitioner>
<id value="695d0991-5e03-46df-934a-85a28acd95c1"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"/>
</meta>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PRN"/>
<display value="Provider number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1922071448"/>
<assigner>
<display
value="Centers for Medicare & Medicaid Services"/>
</assigner>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
<display value="Tax ID number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="00000000"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1639285034"/>
</identifier>
<name>
<use value="official"/>
<family value="CRUZ"/>
<given value="MARISSA"/>
</name>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<resource>
<RelatedPerson>
<id value="4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-relatedPerson"/>
</meta>
<patient>
<reference
value="urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c"/>
<type value="Patient"/>
</patient>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-RoleCode"/>
<code value="SIGOTHR"/>
<display value="significant other"/>
</coding>
</relationship>
<name>
<use value="official"/>
<family value="Smith"/>
<given value="Bob Paul"/>
</name>
<telecom>
<system value="phone"/>
<value value="1234567890"/>
<use value="mobile"/>
</telecom>
<birthDate value="1972-10-29"/>
</RelatedPerson>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:5c2e19ac-8227-4de5-a893-069dec07448e"/>
<resource>
<Coverage>
<id value="b0574bf9-d016-4af7-a895-269abd739db3"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/IssuedDate">
<valueDate value="2023-02-26"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="pay"/>
<display value="Pay"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</subscriber>
<subscriberId value="EYE00044137"/>
<beneficiary>
<reference
value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2023-02-08"/>
<end value="2199-12-31"/>
</period>
<payor>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxbin"/>
<display value="RX BIN"/>
</coding>
</type>
<value value="600426"/>
<name value="BIN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxpcn"/>
<display value="RX PCN"/>
</coding>
</type>
<value value="54"/>
<name value="PCN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="EC38532005"/>
<name value="Group Number"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Xolair-Admin"/>
<name value="Xolair Co Pay program"/>
</class>
<order value="1"/>
<network value="Genentech"/>
</Coverage>
</resource>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>