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-copay-request-response-enrollment"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-copay-request-response-bundle"/>
</meta>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/requestId"/>
<value value="42c481a9-7e7e-4d14-ab37-f648e376802d"/>
</identifier>
<type value="message"/>
<timestamp value="2024-04-19T08:10:17-05:00"/>
<entry>
<fullUrl value="urn:uuid:cdd9f845-427b-4a48-a02d-279d80b9e415"/>
<resource>
<MessageHeader>
<id value="cdd9f845-427b-4a48-a02d-279d80b9e415"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-messageheader"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_cdd9f845-427b-4a48-a02d-279d80b9e415"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader cdd9f845-427b-4a48-a02d-279d80b9e415</b></p><a name="cdd9f845-427b-4a48-a02d-279d80b9e415"> </a><a name="hccdd9f845-427b-4a48-a02d-279d80b9e415"> </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>: 2023-03-03 08:10:13-0500</p><p><b>event</b>: uapi-event-type copay-enrollment-insert: copay-enrollment-insert</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>RisRx</td><td><a href="https://www.risrx.com/fhir/v1/enroll">https://www.risrx.com/fhir/v1/enroll</a></td></tr></table><p><b>sender</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-01c31a2f-321d-4c6e-8349-206af8a88088">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; 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>RisRx-Web</td><td><a href="https://risrx.com/hcpportal">https://risrx.com/hcpportal</a></td></tr></table><h3>Responses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td style="display: none">*</td><td>2fa9b704-914f-4a3c-b49f-39e2960ede95</td><td>OK</td></tr></table><p><b>focus</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-6a576317-329d-4fd6-9b37-896cb97436e6">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p></div>
</text>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/message-timestamp">
<valueDateTime value="2023-03-03T08:10:13-05:00"/>
</extension>
<eventCoding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type"/>
<code value="copay-enrollment-insert"/>
</eventCoding>
<destination>
<name value="RisRx"/>
<endpoint value="https://www.risrx.com/fhir/v1/enroll"/>
</destination>
<sender>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<type value="Organization"/>
</sender>
<source>
<name value="RisRx-Web"/>
<endpoint value="https://risrx.com/hcpportal"/>
</source>
<response>
<identifier value="2fa9b704-914f-4a3c-b49f-39e2960ede95"/>
<code value="ok"/>
</response>
<focus>
<reference value="urn:uuid:6a576317-329d-4fd6-9b37-896cb97436e6"/>
<type value="List"/>
</focus>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:6a576317-329d-4fd6-9b37-896cb97436e6"/>
<resource>
<List>
<id value="6a576317-329d-4fd6-9b37-896cb97436e6"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="List_6a576317-329d-4fd6-9b37-896cb97436e6"> </a><p class="res-header-id"><b>Generated Narrative: List 6a576317-329d-4fd6-9b37-896cb97436e6</b></p><a name="6a576317-329d-4fd6-9b37-896cb97436e6"> </a><a name="hc6a576317-329d-4fd6-9b37-896cb97436e6"> </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-uapi-copay-request-response-enrollment.html#urn-uuid-1d68bd2d-4b8d-4e3d-85fc-2632e48e267d">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr><tr><td><a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-01c31a2f-321d-4c6e-8349-206af8a88088">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-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-695d0991-5e03-46df-934a-85a28acd95c1">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-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-4db51d32-65c3-4f8c-959e-0155c6d14545">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-uapi-copay-request-response-enrollment.html#urn-uuid-d5e01ac4-7210-4e10-b288-45adb6b93e66">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</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-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-uapi-copay-request-response-enrollment.html#urn-uuid-4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-ba8a0351-e1f0-42bf-9590-4ea49b444f56">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr><tr><td><a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-d9acfd1d-addc-4e0d-b7a6-ff921bde9236">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr><tr><td><code>urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3</code></td></tr></table></div>
</text>
<status value="current"/>
<mode value="changes"/>
<title value="messageContext"/>
<entry>
<item>
<reference value="urn:uuid:1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"/>
<type value="Task"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
<type value="Practitioner"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<type value="RelatedPerson"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:d5e01ac4-7210-4e10-b288-45adb6b93e66"/>
<type value="QuestionnaireResponse"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df"/>
<type value="Coverage"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311"/>
<type value="Coverage"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330"/>
<type value="Organization"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"/>
<type value="ExplanationOfBenefit"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:ba8a0351-e1f0-42bf-9590-4ea49b444f56"/>
<type value="Coverage"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:d9acfd1d-addc-4e0d-b7a6-ff921bde9236"/>
<type value="ExplanationOfBenefit"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3"/>
<type value="Coverage"/>
</item>
</entry>
</List>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"/>
<resource>
<Task>
<id value="1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Task_1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"> </a><p class="res-header-id"><b>Generated Narrative: Task 1d68bd2d-4b8d-4e3d-85fc-2632e48e267d</b></p><a name="1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"> </a><a name="hc1d68bd2d-4b8d-4e3d-85fc-2632e48e267d"> </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-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>authoredOn</b>: 2023-01-23 08:10:13-0500</p><p><b>requester</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-01c31a2f-321d-4c6e-8349-206af8a88088">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; 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 520d92fe-360c-4bad-98ab-9af941a43a9b}">520d92fe-360c-4bad-98ab-9af941a43a9b</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 135cc659-da2f-4f7b-afec-5b7334ae5bc0}">135cc659-da2f-4f7b-afec-5b7334ae5bc0</span></p></blockquote></div>
</text>
<status value="requested"/>
<intent value="plan"/>
<code>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-sr-type"/>
<code value="copay"/>
</coding>
</code>
<for>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</for>
<authoredOn value="2023-01-23T08:10:13-05:00"/>
<requester>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<type value="Organization"/>
</requester>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="enroll-by-id"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-enrollby-id"/>
<code value="1"/>
<display value="Patient"/>
</coding>
</valueCodeableConcept>
</input>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="520d92fe-360c-4bad-98ab-9af941a43a9b"/>
</coding>
</valueCodeableConcept>
</input>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="135cc659-da2f-4f7b-afec-5b7334ae5bc0"/>
</coding>
</valueCodeableConcept>
</input>
</Task>
</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>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_3fd08ef2-34a2-4191-ad04-44353c2f133a"> </a><p class="res-header-id"><b>Generated Narrative: Patient 3fd08ef2-34a2-4191-ad04-44353c2f133a</b></p><a name="3fd08ef2-34a2-4191-ad04-44353c2f133a"> </a><a name="hc3fd08ef2-34a2-4191-ad04-44353c2f133a"> </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 Tom Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: 12220c4c-b03b-4ebc-9bb7-1c5ddafbb30c (use: usual, ))</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>Managing Organization: <code>urn:uuid:cf3f3cea-f679-4e30-891b-457e4dd46468</code></li></ul></td></tr></table></div>
</text>
<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:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<resource>
<Organization>
<id value="01c31a2f-321d-4c6e-8349-206af8a88088"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_01c31a2f-321d-4c6e-8349-206af8a88088"> </a><p class="res-header-id"><b>Generated Narrative: Organization 01c31a2f-321d-4c6e-8349-206af8a88088</b></p><a name="01c31a2f-321d-4c6e-8349-206af8a88088"> </a><a name="hc01c31a2f-321d-4c6e-8349-206af8a88088"> </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 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type prov}">Healthcare Provider</span></p><p><b>name</b>: Mid Atlantic Retina</p><p><b>telecom</b>: <a href="mailto:mar@example.com">mar@example.com</a></p><p><b>address</b>: 8 Ranoldo Terrace Cherry Hill NJ 08034 US </p><blockquote><p><b>contact</b></p><p><b>name</b>: Venus Yardav (Official)</p><p><b>telecom</b>: ph: 8882704882(Work), fax: 8179974042(Work)</p></blockquote></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://vendor.com/ab"/>
<value value="HOSP-12345"/>
<assigner>
<display value="AB Vendor"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Mid Atlantic Retina"/>
<telecom>
<system value="email"/>
<value value="mar@example.com"/>
</telecom>
<address>
<line value="8 Ranoldo Terrace"/>
<city value="Cherry Hill"/>
<state value="NJ"/>
<postalCode value="08034"/>
<country value="US"/>
</address>
<contact>
<name>
<use value="official"/>
<family value="Yardav"/>
<given value="Venus"/>
</name>
<telecom>
<system value="phone"/>
<value value="8882704882"/>
<use value="work"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="fax"/>
<value value="8179974042"/>
<use value="work"/>
<rank value="2"/>
</telecom>
</contact>
</Organization>
</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>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Practitioner_695d0991-5e03-46df-934a-85a28acd95c1"> </a><p class="res-header-id"><b>Generated Narrative: Practitioner 695d0991-5e03-46df-934a-85a28acd95c1</b></p><a name="695d0991-5e03-46df-934a-85a28acd95c1"> </a><a name="hc695d0991-5e03-46df-934a-85a28acd95c1"> </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>identifier</b>: Provider number/1922071448 (use: official, ), Tax ID number/00000000 (use: official, ), National provider identifier/1639285034 (use: official, )</p><p><b>name</b>: MARISSA CRUZ (Official)</p></div>
</text>
<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>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="RelatedPerson_4db51d32-65c3-4f8c-959e-0155c6d14545"> </a><p class="res-header-id"><b>Generated Narrative: RelatedPerson 4db51d32-65c3-4f8c-959e-0155c6d14545</b></p><a name="4db51d32-65c3-4f8c-959e-0155c6d14545"> </a><a name="hc4db51d32-65c3-4f8c-959e-0155c6d14545"> </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: 1234567890(Mobile)</p><p><b>birthDate</b>: 1972-10-29</p></div>
</text>
<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:d5e01ac4-7210-4e10-b288-45adb6b93e66"/>
<resource>
<QuestionnaireResponse>
<id value="d5e01ac4-7210-4e10-b288-45adb6b93e66"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="QuestionnaireResponse_d5e01ac4-7210-4e10-b288-45adb6b93e66"> </a><p class="res-header-id"><b>Generated Narrative: QuestionnaireResponse d5e01ac4-7210-4e10-b288-45adb6b93e66</b></p><a name="d5e01ac4-7210-4e10-b288-45adb6b93e66"> </a><a name="hcd5e01ac4-7210-4e10-b288-45adb6b93e66"> </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,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" 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"/> d5e01ac4-7210-4e10-b288-45adb6b93e66</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/4321</td></tr>
<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">Do you consent to enroll in the XOLAIR Co-pay Program for drug and administration assistance?</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>
<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"/> 18-years-or-older</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">Are you 18 years of age or older?</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>
<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"/> fda-approved-indications</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">Are you using XOLAIR for one of the following FDA-approved indications?</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"><span><span>[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.</span></span></td></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_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">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.</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>
<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">Are you using a federal or state-funded insurance 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>
<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 do you 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">DC</td></tr>
<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">Are you currently receiving XOLAIR 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>
<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">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?</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>
<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">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.</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>
<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"/> 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.
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.</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">Agree</td></tr>
<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>
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<status value="completed"/>
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<type value="Patient"/>
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<linkId value="consent-to-enroll"/>
<text
value="Do you consent to enroll in the XOLAIR Co-pay Program for drug and administration assistance?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="18-years-or-older"/>
<text value="Are you 18 years of age or older?"/>
<answer>
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<text
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<display
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</valueCoding>
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<item>
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<answer>
<valueString value="Yes"/>
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<item>
<linkId value="federal-state-funded-insurance"/>
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<answer>
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<linkId value="residence-state"/>
<text value="What state do you live in?"/>
<answer>
<valueString value="DC"/>
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<valueString value="No"/>
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<answer>
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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."/>
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<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>
</text>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="DRUGPOL"/>
<display value="drug policy"/>
</coding>
</type>
<subscriber>
<reference value="urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a"/>
<type value="RelatedPerson"/>
</subscriber>
<subscriberId value="4353"/>
<beneficiary>
<reference value="urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2023-01-01"/>
</period>
<payor>
<reference value="urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330"/>
<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="K3456"/>
<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="K334455"/>
<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="KAI2345"/>
<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="HMO"/>
<name value="Plan"/>
</class>
<order value="1"/>
<network value="CVS Specialty"/>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f"/>
<resource>
<Organization>
<id value="d3637025-883d-4678-9e0a-1d243a338f9f"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<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 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}">Insurance Company</span></p><p><b>name</b>: Dakotacare</p><p><b>telecom</b>: ph: 8778472862(Work)</p></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://vendor.com/ab"/>
<value value="PAY-111"/>
<assigner>
<display value="AB Vendor"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="ins"/>
</coding>
</type>
<name value="Dakotacare"/>
<telecom>
<system value="phone"/>
<value value="8778472862"/>
<use value="work"/>
<rank value="1"/>
</telecom>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330"/>
<resource>
<Organization>
<id value="982e97af-668d-41ef-b9f9-2bbc4a059330"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<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 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}">Insurance Company</span></p><p><b>name</b>: Pharmacare</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>
</text>
<identifier>
<use value="usual"/>
<system value="http://vendor.com/ab"/>
<value value="PAY-145"/>
<assigner>
<display value="Ph Vendor"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="ins"/>
</coding>
</type>
<name value="Pharmacare"/>
<telecom>
<system value="phone"/>
</telecom>
<contact>
<telecom>
<system value="phone"/>
<value value="8778472862"/>
<use value="work"/>
<rank value="1"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"/>
<resource>
<ExplanationOfBenefit>
<id value="4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ExplanationOfBenefit_4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"> </a><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit 4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d</b></p><a name="4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"> </a><a name="hc4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"> </a><p><b>identifier</b>: <code>http://risrx.com/enrollmentId</code>/52f6c814-d858-4f57-a797-a6b065e9d655 (use: usual, )</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:">pharmacy</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>created</b>: 2023-02-07 08:10:13-0500</p><p><b>insurer</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-d02db104-a75c-433f-8764-9778c2e20626">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>provider</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-695d0991-5e03-46df-934a-85a28acd95c1">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>outcome</b>: Complete</p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-ba8a0351-e1f0-42bf-9590-4ea49b444f56">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></td></tr></table></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/enrollmentId"/>
<value value="52f6c814-d858-4f57-a797-a6b065e9d655"/>
</identifier>
<status value="active"/>
<type>
<coding>
<code value="pharmacy"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
</patient>
<created value="2023-02-07T08:10:13-05:00"/>
<insurer>
<reference value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>
<reference value="urn:uuid:ba8a0351-e1f0-42bf-9590-4ea49b444f56"/>
</coverage>
</insurance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:ba8a0351-e1f0-42bf-9590-4ea49b444f56"/>
<resource>
<Coverage>
<id value="ba8a0351-e1f0-42bf-9590-4ea49b444f56"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_ba8a0351-e1f0-42bf-9590-4ea49b444f56"> </a><p class="res-header-id"><b>Generated Narrative: Coverage ba8a0351-e1f0-42bf-9590-4ea49b444f56</b></p><a name="ba8a0351-e1f0-42bf-9590-4ea49b444f56"> </a><a name="hcba8a0351-e1f0-42bf-9590-4ea49b444f56"> </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>UAPI Coverage - Card issuance date</b>: 2023-01-01</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode pay}">Pay</span></p><p><b>subscriber</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>subscriberId</b>: EYE00044117</p><p><b>beneficiary</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>period</b>: 2023-01-01 --> 2023-12-31</p><p><b>payor</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-d02db104-a75c-433f-8764-9778c2e20626">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</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>: 600426</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>: 54</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>: EC38517002</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>: Xolair-Drug</p><p><b>name</b>: Xolair Co Pay program</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Genentech</p></div>
</text>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/IssuedDate">
<valueDate value="2023-01-01"/>
</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="EYE00044117"/>
<beneficiary>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2023-01-01"/>
<end value="2023-12-31"/>
</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="EC38517002"/>
<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-Drug"/>
<name value="Xolair Co Pay program"/>
</class>
<order value="1"/>
<network value="Genentech"/>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:d9acfd1d-addc-4e0d-b7a6-ff921bde9236"/>
<resource>
<ExplanationOfBenefit>
<id value="d9acfd1d-addc-4e0d-b7a6-ff921bde9236"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ExplanationOfBenefit_d9acfd1d-addc-4e0d-b7a6-ff921bde9236"> </a><p class="res-header-id"><b>Generated Narrative: ExplanationOfBenefit d9acfd1d-addc-4e0d-b7a6-ff921bde9236</b></p><a name="d9acfd1d-addc-4e0d-b7a6-ff921bde9236"> </a><a name="hcd9acfd1d-addc-4e0d-b7a6-ff921bde9236"> </a><p><b>identifier</b>: <code>http://risrx.com/enrollmentId</code>/5195d04d-893e-44bd-b71a-d0ab4a7945b3 (use: usual, )</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:">institutional</span></p><p><b>use</b>: Predetermination</p><p><b>patient</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>created</b>: 2023-02-26 21:01:11+0000</p><p><b>insurer</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-d02db104-a75c-433f-8764-9778c2e20626">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>provider</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-695d0991-5e03-46df-934a-85a28acd95c1">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>outcome</b>: Complete</p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>true</td><td><code>urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3</code></td></tr></table></div>
</text>
<identifier>
<use value="usual"/>
<system value="http://risrx.com/enrollmentId"/>
<value value="5195d04d-893e-44bd-b71a-d0ab4a7945b3"/>
</identifier>
<status value="active"/>
<type>
<coding>
<code value="institutional"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
</patient>
<created value="2023-02-26T21:01:11.230Z"/>
<insurer>
<reference value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>
<reference value="urn:uuid:b0574bf9-d016-4af7-a895-269abd739db3"/>
</coverage>
</insurance>
</ExplanationOfBenefit>
</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>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_b0574bf9-d016-4af7-a895-269abd739db3"> </a><p class="res-header-id"><b>Generated Narrative: Coverage b0574bf9-d016-4af7-a895-269abd739db3</b></p><a name="b0574bf9-d016-4af7-a895-269abd739db3"> </a><a name="hcb0574bf9-d016-4af7-a895-269abd739db3"> </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>UAPI Coverage - Card issuance date</b>: 2023-02-26</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode pay}">Pay</span></p><p><b>subscriber</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>subscriberId</b>: EYE00044137</p><p><b>beneficiary</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-3fd08ef2-34a2-4191-ad04-44353c2f133a">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</a></p><p><b>period</b>: 2023-02-08 --> 2199-12-31</p><p><b>payor</b>: <a href="Bundle-uapi-copay-request-response-enrollment.html#urn-uuid-d02db104-a75c-433f-8764-9778c2e20626">Bundle: identifier = http://risrx.com/requestId#42c481a9-7e7e-4d14-ab37-f648e376802d (use: usual, ); type = message; timestamp = 2024-04-19 08:10:17-0500</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>: 600426</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>: 54</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>: EC38532005</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>: Xolair-Admin</p><p><b>name</b>: Xolair Co Pay program</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Genentech</p></div>
</text>
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url="https://fhir.developer.gene.com/StructureDefinition/IssuedDate">
<valueDate value="2023-02-26"/>
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<status value="active"/>
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<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"/>
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<subscriberId value="EYE00044137"/>
<beneficiary>
<reference value="urn:uuid:3fd08ef2-34a2-4191-ad04-44353c2f133a"/>
<type value="Patient"/>
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<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>
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<value value="EC38532005"/>
<name value="Group Number"/>
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<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>
<entry>
<fullUrl value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
<resource>
<Organization>
<id value="d02db104-a75c-433f-8764-9778c2e20626"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_d02db104-a75c-433f-8764-9778c2e20626"> </a><p class="res-header-id"><b>Generated Narrative: Organization d02db104-a75c-433f-8764-9778c2e20626</b></p><a name="d02db104-a75c-433f-8764-9778c2e20626"> </a><a name="hcd02db104-a75c-433f-8764-9778c2e20626"> </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://gene.com</code>/ORG-00002 (use: usual, )</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/organization-type ins}">Insurance Company</span></p><p><b>name</b>: Copay Organization - CRX</p><p><b>telecom</b>: ph: 1800654332211(Work)</p></div>
</text>
<identifier>
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<system value="http://gene.com"/>
<value value="ORG-00002"/>
<assigner>
<display value="Genentech"/>
</assigner>
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<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="ins"/>
</coding>
</type>
<name value="Copay Organization - CRX"/>
<telecom>
<system value="phone"/>
<value value="1800654332211"/>
<use value="work"/>
<rank value="1"/>
</telecom>
</Organization>
</resource>
</entry>
</Bundle>