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 request-response enrollment bundle - success
Profile: UAPI Bundle - Copay Request-Response
Bundle uapi-copay-request-response-enrollment of type message
Entry 1 - fullUrl = urn:uuid:cdd9f845-427b-4a48-a02d-279d80b9e415
Resource MessageHeader:
Profile: UAPI MessageHeader
UAPI MessageHeader Timestamp: 2023-03-03 08:10:13-0500
event: uapi-event-type copay-enrollment-insert: copay-enrollment-insert
Destinations
Name RisRx Sources
Name RisRx-Web Responses
Identifier Code 2fa9b704-914f-4a3c-b49f-39e2960ede95 OK
Entry 2 - fullUrl = urn:uuid:6a576317-329d-4fd6-9b37-896cb97436e6
Resource List:
messageContext
Mode: Change List Status: Current
Entry 3 - fullUrl = urn:uuid:1d68bd2d-4b8d-4e3d-85fc-2632e48e267d
Resource Task:
status: Requested
intent: Plan
code: Copay
authoredOn: 2023-01-23 08:10:13-0500
input
type: enroll-by-id
value: Patient
input
type: brandId
value: 520d92fe-360c-4bad-98ab-9af941a43a9b
input
type: brandId
value: 135cc659-da2f-4f7b-afec-5b7334ae5bc0
Entry 4 - 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 5 - fullUrl = urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/HOSP-12345 (use: usual, )type: Healthcare Provider
name: Mid Atlantic Retina
contact
telecom: mar@example.com
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
contact
name: Venus Yardav (Official)
telecom: ph: 8882704882(Work), fax: 8179974042(Work)
Entry 6 - 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 7 - fullUrl = urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545
Resource RelatedPerson:
Profile: UAPI RelatedPerson
relationship: significant other
name: Bob Paul Smith (Official)
telecom: ph: 1234567890(Mobile)
birthDate: 1972-10-29
Entry 8 - fullUrl = urn:uuid:d5e01ac4-7210-4e10-b288-45adb6b93e66
Resource QuestionnaireResponse:
LinkID Text Definition Answer d5e01ac4-7210-4e10-b288-45adb6b93e66
Questionnaire:https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/4321 consent-to-enroll
Do you consent to enroll in the XOLAIR Co-pay Program for drug and administration assistance? Yes Are you 18 years of age or older? Yes Are you using XOLAIR for one of the following FDA-approved indications? [not stated] combination: Moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids. A skin or blood test is performed to see if you have allergies to year-round allergens. It is not known if Xolair is safe and effective in people with asthma under 6 years of age. Are you on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace. Yes Are you using a federal or state-funded insurance program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE. No What state do you live in? DC Are you currently receiving XOLAIR from the Genentech Patient Foundation? No Are you currently receiving assistance from any other charitable organization for any of your out-of-pocket costs that are covered by the XOLAIR Co-pay Program? No I acknowledge and agree that any of my information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to my medical condition, treatments, and health insurance 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. I authorize Genentech to receive, use, and share my personal information in connection with the XOLAIR Co-payProgram. I agree to be contacted by phone, mail, or email about the XOLAIR Co-pay Program. For more information, please see the Genentech Privacy Policy at www.gene.com/privacy- policy. To withdraw from the Program, please contact the Program at (855) 965-2472 Monday through Friday between 9am – 8pm ET. Agree The Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine are not eligible. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the cost associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time. Agree Documentation for this format
Entry 9 - fullUrl = urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: health insurance plan policy
subscriberId: 4353
period: 2023-01-01 --> (ongoing)
class
type: RX BIN
value: K12345
name: BIN
class
type: RX PCN
value: K234516
name: PCN
class
type: Group
value: KAI2345
name: Group Number
class
type: Plan
value: HMO
name: Plan
order: 1
network: Kaiser
Entry 10 - fullUrl = urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311
Resource Coverage:
Profile: UAPI Coverage
status: Active
type: drug policy
subscriberId: 4353
period: 2023-01-01 --> (ongoing)
class
type: RX BIN
value: K3456
name: BIN
class
type: RX PCN
value: K334455
name: PCN
class
type: Group
value: KAI2345
name: Group Number
class
type: Plan
value: HMO
name: Plan
order: 1
network: CVS Specialty
Entry 11 - fullUrl = urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/PAY-111 (use: usual, )type: Insurance Company
name: Dakotacare
Contacts
Telecom ph: 8778472862(Work)
Entry 12 - fullUrl = urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330
Resource Organization:
Profile: UAPI Organization
identifier:
http://vendor.com/ab/PAY-145 (use: usual, )type: Insurance Company
name: Pharmacare
contact
telecom: ph: -unknown-
contact
telecom: ph: 8778472862(Work)
Entry 13 - fullUrl = urn:uuid:4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d
Resource ExplanationOfBenefit:
identifier:
http://risrx.com/enrollmentId/52f6c814-d858-4f57-a797-a6b065e9d655 (use: usual, )status: Active
type: pharmacy
use: Predetermination
created: 2023-02-07 08:10:13-0500
outcome: complete
Insurances
Focal Coverage true Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500
Entry 14 - fullUrl = urn:uuid:ba8a0351-e1f0-42bf-9590-4ea49b444f56
Resource Coverage:
Profile: UAPI Coverage
UAPI Coverage - Card issuance date: 2023-01-01
status: Active
type: Pay
subscriberId: EYE00044117
period: 2023-01-01 --> 2023-12-31
class
type: RX BIN
value: 600426
name: BIN
class
type: RX PCN
value: 54
name: PCN
class
type: Group
value: EC38517002
name: Group Number
class
type: Plan
value: Xolair-Drug
name: Xolair Co Pay program
order: 1
network: Genentech
Entry 15 - fullUrl = urn:uuid:d9acfd1d-addc-4e0d-b7a6-ff921bde9236
Resource ExplanationOfBenefit:
identifier:
http://risrx.com/enrollmentId/5195d04d-893e-44bd-b71a-d0ab4a7945b3 (use: usual, )status: Active
type: institutional
use: Predetermination
created: 2023-02-26 21:01:11+0000
outcome: complete
Insurances
Focal Coverage true urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3
Entry 16 - 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
subscriberId: EYE00044137
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 17 - fullUrl = urn:uuid:d02db104-a75c-433f-8764-9778c2e20626
Resource Organization:
Profile: UAPI Organization
identifier:
http://gene.com/ORG-00002 (use: usual, )type: Insurance Company
name: Copay Organization - CRX
Contacts
Telecom ph: 1800654332211(Work)