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-status-update-3"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-status-update"/>
</meta>
<type value="message"/>
<timestamp value="2020-03-11T08:10:13-05:00"/>
<entry>
<fullUrl value="urn:uuid:5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"/>
<resource>
<MessageHeader>
<id value="5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-messageheader"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="MessageHeader_5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"> </a><p class="res-header-id"><b>Generated Narrative: MessageHeader 5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa</b></p><a name="5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"> </a><a name="hc5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"> </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>event</b>: uapi-event-type status-update: status-update</p><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>Genentech-PACT</td><td><a href="https://genentech-pps.my.salesforce.com">https://genentech-pps.my.salesforce.com</a></td></tr></table><p><b>focus</b>: <a href="Bundle-7c8f5054-015b-4bce-99f5-4160a82a4225.html#urn-uuid-8e055260-dd74-4c89-9ccf-3d2f47135ee0">Bundle: identifier = Resource identifier: 7c8f5054-015b-4bce-99f5-4160a82a4225; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p></div>
</text>
<eventCoding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type"/>
<code value="status-update"/>
</eventCoding>
<sender>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<type value="Organization"/>
</sender>
<source>
<name value="Genentech-PACT"/>
<endpoint value="https://genentech-pps.my.salesforce.com"/>
</source>
<focus>
<reference value="urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0"/>
<type value="List"/>
</focus>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0"/>
<resource>
<List>
<id value="8e055260-dd74-4c89-9ccf-3d2f47135ee0"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="List_8e055260-dd74-4c89-9ccf-3d2f47135ee0"> </a><p class="res-header-id"><b>Generated Narrative: List 8e055260-dd74-4c89-9ccf-3d2f47135ee0</b></p><a name="8e055260-dd74-4c89-9ccf-3d2f47135ee0"> </a><a name="hc8e055260-dd74-4c89-9ccf-3d2f47135ee0"> </a><h2>messageContext</h2><table class="clstu"><tr><td>Mode: Change List </td><td>Status: Current </td></tr><tr><td/></tr></table><table class="grid"><tr style="backgound-color: #eeeeee"><td><b>Items</b></td></tr><tr><td><a href="Bundle-uapi-query-response-1-gpf.html#urn-uuid-b3d46ea3-62e6-4171-b818-d64712edfe55">Bundle: type = message; timestamp = 2020-03-11 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-uapi-status-update-3.html#urn-uuid-a0e6a72c-a35b-4e1c-890e-6d34ed51d4de">Bundle: type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr><tr><td><a href="Bundle-uapi-status-update-3.html#urn-uuid-e89b0285-4582-4b1b-a448-f2cc467664f4">Bundle: type = message; timestamp = 2020-03-11 08:10:13-0500</a></td></tr></table></div>
</text>
<status value="current"/>
<mode value="changes"/>
<title value="messageContext"/>
<entry>
<item>
<reference value="urn:uuid:b3d46ea3-62e6-4171-b818-d64712edfe55"/>
<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:a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"/>
<type value="CoverageEligibilityRequest"/>
</item>
</entry>
<entry>
<item>
<reference value="urn:uuid:e89b0285-4582-4b1b-a448-f2cc467664f4"/>
<type value="CoverageEligibilityResponse"/>
</item>
</entry>
</List>
</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, ), <code>http://dev.gene.com/fhir/mulesoft</code>/Vendor_AB_HOSP-12345 (use: official, )</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>: ph: -unknown-</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>
<identifier>
<use value="official"/>
<system value="http://dev.gene.com/fhir/mulesoft"/>
<value value="Vendor_AB_HOSP-12345"/>
<assigner>
<display value="UAPI Process API Mulesoft"/>
</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="phone"/>
</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:7c0c0017-e08d-4a14-9889-9eea26303ff2"/>
<resource>
<Patient>
<id value="7c0c0017-e08d-4a14-9889-9eea26303ff2"/>
<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_7c0c0017-e08d-4a14-9889-9eea26303ff2"> </a><p class="res-header-id"><b>Generated Narrative: Patient 7c0c0017-e08d-4a14-9889-9eea26303ff2</b></p><a name="7c0c0017-e08d-4a14-9889-9eea26303ff2"> </a><a name="hc7c0c0017-e08d-4a14-9889-9eea26303ff2"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-patient.html">UAPI Patient</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">Ryan Michaelson (official) Male, DoB: 1972-10-29 ( Patient internal identifier: MPAT-000123 (use: usual, ))</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="Other Id (see the one above)">Other Id:</td><td colspan="3">Patient internal identifier/540002 (use: official, )</td></tr><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: <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></li></ul></td></tr></table></div>
</text>
<identifier>
<use value="official"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PI"/>
<display value="Patient internal identifier"/>
</coding>
</type>
<system value="http://vendor.com/ab"/>
<value value="540002"/>
<assigner>
<display value="AB Vendor"/>
</assigner>
</identifier>
<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://dev.gene.com/patientmaster"/>
<value value="MPAT-000123"/>
<assigner>
<display value="Genentech Patient Master"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Michaelson"/>
<given value="Ryan"/>
</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:01c31a2f-321d-4c6e-8349-206af8a88088"/>
</managingOrganization>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"/>
<resource>
<CoverageEligibilityRequest>
<id value="a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage-eligibility-request"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="CoverageEligibilityRequest_a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"> </a><p class="res-header-id"><b>Generated Narrative: CoverageEligibilityRequest a0e6a72c-a35b-4e1c-890e-6d34ed51d4de</b></p><a name="a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"> </a><a name="hca0e6a72c-a35b-4e1c-890e-6d34ed51d4de"> </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-eligibility-request.html">UAPI CoverageEligibilityRequest</a></p></div><p><b>UAPI CoverageEligibilityRequest ServiceRequestType</b>: <span title="Codes:{https://fhir.developer.gene.com/CodeSystem/uapi-sr-type bipa}">Benefit Investigation / Prior Authorization</span></p><p><b>UAPI CoverageEligibilityRequest Product</b>: <span title="Codes:{https://fhir.developer.gene.com/CodeSystem/uapi-product-name lucentis}">Lucentis</span></p><p><b>identifier</b>: <code>https://fhir.developer.gene.com/enrollment/bundle-enrollment-id</code>/c78bde64-95e8-41f9-8a37-b2ac9aaf33d6 (use: old, ), <code>https://fhir.developer.gene.com/enrollment/Case</code>/05971219 (use: old, ), <code>https://genentech-pps.my.salesforce.com/ProductCoverageID</code>/PC-4856067 (use: official, )</p><p><b>status</b>: Active</p><p><b>purpose</b>: Coverage benefits</p><p><b>patient</b>: <a href="Bundle-uapi-status-update-1.html#urn-uuid-7c0c0017-e08d-4a14-9889-9eea26303ff2">Bundle: type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>created</b>: 2021-05-27 08:10:13-0500</p><p><b>provider</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><p><b>insurer</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td><a href="#hca0e6a72c-a35b-4e1c-890e-6d34ed51d4de/42b41bdb-1781-49aa-a091-78cdd92129df">Coverage: extension = Calendar Year,jhgfdsd56e5r76; status = active; type = health insurance plan policy; subscriberId = 4353; period = 2021-08-31 --> 2021-09-07; order = 1; network = Dakotacare</a></td></tr></table><blockquote><p><b>item</b></p><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm E11.3513}">Type 2 diab with prolif diab rtnop with macular edema, bi</span></td></tr></table></blockquote><hr/><blockquote><p class="res-header-id"><b>Generated Narrative: Organization #d3637025-883d-4678-9e0a-1d243a338f9f</b></p><a name="a0e6a72c-a35b-4e1c-890e-6d34ed51d4de/d3637025-883d-4678-9e0a-1d243a338f9f"> </a><a name="hca0e6a72c-a35b-4e1c-890e-6d34ed51d4de/d3637025-883d-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></blockquote><hr/><blockquote><p class="res-header-id"><b>Generated Narrative: Coverage #42b41bdb-1781-49aa-a091-78cdd92129df</b></p><a name="a0e6a72c-a35b-4e1c-890e-6d34ed51d4de/42b41bdb-1781-49aa-a091-78cdd92129df"> </a><a name="hca0e6a72c-a35b-4e1c-890e-6d34ed51d4de/42b41bdb-1781-49aa-a091-78cdd92129df"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-coverage.html">UAPI Coverage</a></p></div><p><b>UAPI Coverage Plan Year</b>: Calendar Year</p><p><b>UAPI Coverage Reference Number</b>: jhgfdsd56e5r76</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span></p><p><b>subscriber</b>: <a href="Bundle-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></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>: 2021-08-31 --> 2021-09-07</p><p><b>payor</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class subplan}">SubPlan</span></p><p><b>value</b>: CHAMPVA</p><p><b>name</b>: SubPlan</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>: Miltary</p><p><b>name</b>: Plan</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>: 12344frgr</p><p><b>name</b>: Group</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Dakotacare</p></blockquote></div>
</text>
<contained>
<Organization>
<id value="d3637025-883d-4678-9e0a-1d243a338f9f"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<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>
</contained>
<contained>
<Coverage>
<id value="42b41bdb-1781-49aa-a091-78cdd92129df"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/PlanYear">
<valueString value="Calendar Year"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/ReferenceNumber">
<valueString value="jhgfdsd56e5r76"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="HIP"/>
<display value="health insurance plan policy"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<type value="RelatedPerson"/>
</subscriber>
<subscriberId value="4353"/>
<beneficiary>
<reference
value="urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2021-08-31"/>
<end value="2021-09-07"/>
</period>
<payor>
<reference
value="urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="subplan"/>
<display value="SubPlan"/>
</coding>
</type>
<value value="CHAMPVA"/>
<name value="SubPlan"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Miltary"/>
<name value="Plan"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="12344frgr"/>
<name value="Group"/>
</class>
<order value="1"/>
<network value="Dakotacare"/>
</Coverage>
</contained>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/SRType">
<valueCodeableConcept>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-sr-type"/>
<code value="bipa"/>
<display value="Benefit Investigation / Prior Authorization"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/Product">
<valueCodeableConcept>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-product-name"/>
<code value="lucentis"/>
<display value="Lucentis"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<use value="old"/>
<system
value="https://fhir.developer.gene.com/enrollment/bundle-enrollment-id"/>
<value value="c78bde64-95e8-41f9-8a37-b2ac9aaf33d6"/>
</identifier>
<identifier>
<use value="old"/>
<system value="https://fhir.developer.gene.com/enrollment/Case"/>
<value value="05971219"/>
</identifier>
<identifier>
<use value="official"/>
<system
value="https://genentech-pps.my.salesforce.com/ProductCoverageID"/>
<value value="PC-4856067"/>
</identifier>
<status value="active"/>
<purpose value="benefits"/>
<patient>
<reference value="urn:uuid:7c0c0017-e08d-4a14-9889-9eea26303ff2"/>
<type value="Patient"/>
</patient>
<created value="2021-05-27T08:10:13-05:00"/>
<provider>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<type value="Organization"/>
</provider>
<insurer>
<reference value="urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f"/>
<type value="Organization"/>
</insurer>
<insurance>
<coverage>
<reference value="#42b41bdb-1781-49aa-a091-78cdd92129df"/>
</coverage>
</insurance>
<item>
<diagnosis>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="E11.3513"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
</item>
</CoverageEligibilityRequest>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:e89b0285-4582-4b1b-a448-f2cc467664f4"/>
<resource>
<CoverageEligibilityResponse>
<id value="e89b0285-4582-4b1b-a448-f2cc467664f4"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage-eligibility-response"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="CoverageEligibilityResponse_e89b0285-4582-4b1b-a448-f2cc467664f4"> </a><p class="res-header-id"><b>Generated Narrative: CoverageEligibilityResponse e89b0285-4582-4b1b-a448-f2cc467664f4</b></p><a name="e89b0285-4582-4b1b-a448-f2cc467664f4"> </a><a name="hce89b0285-4582-4b1b-a448-f2cc467664f4"> </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-eligibility-response.html">UAPI CoverageEligibilityResponse</a></p></div><p><b>UAPI CoverageEligibilityResponse Status</b>: <span title="Codes:{https://fhir.developer.gene.com/CodeSystem/uapi-coverage-outcome approved}">Approved</span></p><p><b>UAPI PreD Est. TAT</b>: 5-7 Business Days</p><p><b>UAPI PCP Referral Required?</b>: No</p><p><b>UAPI PCP Referral Effective Date</b>: 2022-05-14</p><p><b>UAPI PCP Referral On-file?</b>: Yes</p><p><b>UAPI PCP Referral Recertification Date</b>: 2022-05-14</p><p><b>UAPI Spend Down Frequency</b>: 6</p><p><b>UAPI Peer to Peer Available</b>: Yes</p><p><b>UAPI # of Appeals Allowed</b>: 2</p><p><b>UAPI Appeal Submission Deadline</b>: 2022-05-14</p><p><b>UAPI Additional Documents Required</b>: Denial Letter</p><p><b>UAPI Estimated Appeal TAT</b>: 4</p><p><b>identifier</b>: <code>https://fhir.developer.gene.com/enrollment/bundle-enrollment-id</code>/c78bde64-95e8-41f9-8a37-b2ac9aaf33d6 (use: old, ), <code>https://fhir.developer.gene.com/enrollment/Case</code>/05971219 (use: old, ), <code>https://genentech-pps.my.salesforce.com/ProductCoverageID</code>/PC-4856067 (use: official, )</p><p><b>status</b>: Active</p><p><b>purpose</b>: Coverage benefits</p><p><b>patient</b>: <a href="Bundle-uapi-status-update-1.html#urn-uuid-7c0c0017-e08d-4a14-9889-9eea26303ff2">Bundle: type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>serviced</b>: 2021-06-01</p><p><b>created</b>: 2021-05-27 08:10:13-0500</p><p><b>request</b>: <a href="Bundle-uapi-status-update-3.html#urn-uuid-a0e6a72c-a35b-4e1c-890e-6d34ed51d4de">Bundle: type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><p><b>outcome</b>: Complete</p><p><b>disposition</b>: Yes, if medically necessary</p><p><b>insurer</b>: <a href="#hce89b0285-4582-4b1b-a448-f2cc467664f4/d3637025-883d-4678-9e0a-1d243a338f9f">Organization Dakotacare</a></p><blockquote><p><b>insurance</b></p><p><b>coverage</b>: <a href="#hce89b0285-4582-4b1b-a448-f2cc467664f4/42b41bdb-1781-49aa-a091-78cdd92129df">Coverage: extension = Calendar Year,jhgfdsd56e5r76; status = active; type = health insurance plan policy; subscriberId = 4353; period = 2021-08-31 --> 2021-09-07; order = 1; network = Dakotacare</a></p><blockquote><p><b>item</b></p><p><b>productOrService</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service billing}">Billing Code</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type fullBI}">Full BI</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DeductibleApply}">Does Deductible Apply?</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type doesIndDedApplyFamily}">does ind ded apply to family</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type FamDedMetBefore}">Must Fam Ded Be Met Before Bene Cov</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type OOPApply}">Does OOP Apply</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type IndividualOOPFamily}">Does Individual OOP Apply to Family</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type 100%Cov}">100% Cov only if Family OOP Met</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type InsurerCostShare}">Insurer Cost Share %</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type PatientCostShare}">Patient Cost Share %</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type BuyBill}">Buy and Bill</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DrugTierLevel}">Drug Tier Level</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type PatientCostInitial}">Patient Cost Share % **Initial Coverage Stage</span></p><p><b>allowed</b>: 25</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DaysSupplyInitial}">Day Supply **Initial Coverage Stage</span></p><p><b>allowed</b>: 30 day supply</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DrugCopayInitial}">Drug Copay **Initial Coverage Stage</span></p><p><b>allowed</b>: 30.00</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type PatientCostCatastrophic}">Patient Cost Share % **Catastrophic Coverage Stage</span></p><p><b>allowed</b>: 15</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DrugCopayCatastrophic}">Drug Co-pay **Catastrophic Coverage Stage</span></p><p><b>allowed</b>: 10</p></blockquote><p><b>authorizationRequired</b>: true</p></blockquote><blockquote><p><b>item</b></p><p><b>productOrService</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service admin}">Admin Code</span></p><p><b>unit</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-insurance-unit indivitual}">Indivitual</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type deductible}">deductible</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type OOPMax}">OOP MAx</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type MaxBenefit/Year}">Max Benefit/Year</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type MaxLifetimeAmount}">Max Lifetime Amount</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type SpentDownAmount}">Spent Down Amount</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type CoverageGap}">Coverage Gap</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><p><b>authorizationRequired</b>: true</p><p><b>authorizationSupporting</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting form}">Form</span></p></blockquote><blockquote><p><b>item</b></p><p><b>productOrService</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service billing}">Billing Code</span></p><p><b>unit</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-insurance-unit family}">Family</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type deductible}">deductible</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type OOPMax}">OOP Max</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type MaxBenefit/Year}">Max Benefit/Year</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p><p><b>used</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>productOrService</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service billing}">Billing Code</span></p><p><b>network</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/benefit-network in}">In Network</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DrugCo-Pay}">Drug Co-Pay</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type SpecialistCo-Pay}">Specialist Co-Pay</span></p><p><b>allowed</b>: <span title="US Dollar">$25.00</span> (USD)</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type DeductibleApplyOOP}">Does Deductible Apply to OOP</span></p><p><b>allowed</b>: Yes</p></blockquote></blockquote></blockquote><hr/><blockquote><p class="res-header-id"><b>Generated Narrative: Organization #d3637025-883d-4678-9e0a-1d243a338f9f</b></p><a name="e89b0285-4582-4b1b-a448-f2cc467664f4/d3637025-883d-4678-9e0a-1d243a338f9f"> </a><a name="hce89b0285-4582-4b1b-a448-f2cc467664f4/d3637025-883d-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></blockquote><hr/><blockquote><p class="res-header-id"><b>Generated Narrative: Coverage #42b41bdb-1781-49aa-a091-78cdd92129df</b></p><a name="e89b0285-4582-4b1b-a448-f2cc467664f4/42b41bdb-1781-49aa-a091-78cdd92129df"> </a><a name="hce89b0285-4582-4b1b-a448-f2cc467664f4/42b41bdb-1781-49aa-a091-78cdd92129df"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-coverage.html">UAPI Coverage</a></p></div><p><b>UAPI Coverage Plan Year</b>: Calendar Year</p><p><b>UAPI Coverage Reference Number</b>: jhgfdsd56e5r76</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span></p><p><b>subscriber</b>: <a href="Bundle-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></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>: 2021-08-31 --> 2021-09-07</p><p><b>payor</b>: <a href="Bundle-13778a5c-73de-46e4-bb5a-3781a5c93b5e.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">Bundle: identifier = Resource identifier: da5e1572-cc88-4e4d-9899-e3553f680d87; type = message; timestamp = 2020-03-11 08:10:13-0500</a></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/coverage-class subplan}">SubPlan</span></p><p><b>value</b>: CHAMPVA</p><p><b>name</b>: SubPlan</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>: Miltary</p><p><b>name</b>: Plan</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>: 12344frgr</p><p><b>name</b>: Group</p></blockquote><p><b>order</b>: 1</p><p><b>network</b>: Dakotacare</p></blockquote></div>
</text>
<contained>
<Organization>
<id value="d3637025-883d-4678-9e0a-1d243a338f9f"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<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>
</contained>
<contained>
<Coverage>
<id value="42b41bdb-1781-49aa-a091-78cdd92129df"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/PlanYear">
<valueString value="Calendar Year"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/ReferenceNumber">
<valueString value="jhgfdsd56e5r76"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="HIP"/>
<display value="health insurance plan policy"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545"/>
<type value="RelatedPerson"/>
</subscriber>
<subscriberId value="4353"/>
<beneficiary>
<reference
value="urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2021-08-31"/>
<end value="2021-09-07"/>
</period>
<payor>
<reference
value="urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="subplan"/>
<display value="SubPlan"/>
</coding>
</type>
<value value="CHAMPVA"/>
<name value="SubPlan"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Miltary"/>
<name value="Plan"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="12344frgr"/>
<name value="Group"/>
</class>
<order value="1"/>
<network value="Dakotacare"/>
</Coverage>
</contained>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/statusOutcome">
<valueCodeableConcept>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-coverage-outcome"/>
<code value="approved"/>
<display value="Approved"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/predAuthTAT">
<valueString value="5-7 Business Days"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/pcpReferralRequired">
<valueString value="No"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/preReferralEffectiveDate">
<valueString value="2022-05-14"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/pcpReferralOnFile">
<valueString value="Yes"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/pcpReferralRecertificationDate">
<valueString value="2022-05-14"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/spendDownFrequency">
<valueString value="6"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/peerToPeerAvailable">
<valueString value="Yes"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/noOfAppealsAllowed">
<valueString value="2"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/appealSubmissionDeadline">
<valueString value="2022-05-14"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/additionalDocumentsRequired">
<valueString value="Denial Letter"/>
</extension>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/estimatedAppealTAT">
<valueString value="4"/>
</extension>
<identifier>
<use value="old"/>
<system
value="https://fhir.developer.gene.com/enrollment/bundle-enrollment-id"/>
<value value="c78bde64-95e8-41f9-8a37-b2ac9aaf33d6"/>
</identifier>
<identifier>
<use value="old"/>
<system value="https://fhir.developer.gene.com/enrollment/Case"/>
<value value="05971219"/>
</identifier>
<identifier>
<use value="official"/>
<system
value="https://genentech-pps.my.salesforce.com/ProductCoverageID"/>
<value value="PC-4856067"/>
</identifier>
<status value="active"/>
<purpose value="benefits"/>
<patient>
<reference value="urn:uuid:7c0c0017-e08d-4a14-9889-9eea26303ff2"/>
<type value="Patient"/>
</patient>
<servicedDate value="2021-06-01"/>
<created value="2021-05-27T08:10:13-05:00"/>
<request>
<reference value="urn:uuid:a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"/>
<type value="CoverageEligibilityRequest"/>
</request>
<outcome value="complete"/>
<disposition value="Yes, if medically necessary"/>
<insurer>
<reference value="#d3637025-883d-4678-9e0a-1d243a338f9f"/>
<type value="Organization"/>
</insurer>
<insurance>
<coverage>
<reference value="#42b41bdb-1781-49aa-a091-78cdd92129df"/>
</coverage>
<item>
<productOrService>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service"/>
<code value="billing"/>
<display value="Billing Code"/>
</coding>
</productOrService>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="fullBI"/>
<display value="Full BI"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DeductibleApply"/>
<display value="Does Deductible Apply?"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="doesIndDedApplyFamily"/>
<display value="does ind ded apply to family"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="FamDedMetBefore"/>
<display value="Must Fam Ded Be Met Before Bene Cov"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="OOPApply"/>
<display value="Does OOP Apply"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="IndividualOOPFamily"/>
<display value="Does Individual OOP Apply to Family"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="100%Cov"/>
<display value="100% Cov only if Family OOP Met"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="InsurerCostShare"/>
<display value="Insurer Cost Share %"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="PatientCostShare"/>
<display value="Patient Cost Share %"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="BuyBill"/>
<display value="Buy and Bill"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DrugTierLevel"/>
<display value="Drug Tier Level"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="PatientCostInitial"/>
<display
value="Patient Cost Share % **Initial Coverage Stage"/>
</coding>
</type>
<allowedString value="25"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DaysSupplyInitial"/>
<display value="Day Supply **Initial Coverage Stage"/>
</coding>
</type>
<allowedString value="30 day supply"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DrugCopayInitial"/>
<display value="Drug Copay **Initial Coverage Stage"/>
</coding>
</type>
<allowedString value="30.00"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="PatientCostCatastrophic"/>
<display
value="Patient Cost Share % **Catastrophic Coverage Stage"/>
</coding>
</type>
<allowedString value="15"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DrugCopayCatastrophic"/>
<display value="Drug Co-pay **Catastrophic Coverage Stage"/>
</coding>
</type>
<allowedString value="10"/>
</benefit>
<authorizationRequired value="true"/>
</item>
<item>
<productOrService>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service"/>
<code value="admin"/>
<display value="Admin Code"/>
</coding>
</productOrService>
<unit>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-insurance-unit"/>
<code value="indivitual"/>
<display value="Indivitual"/>
</coding>
</unit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="deductible"/>
<display value="deductible"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="OOPMax"/>
<display value="OOP MAx"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="MaxBenefit/Year"/>
<display value="Max Benefit/Year"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="MaxLifetimeAmount"/>
<display value="Max Lifetime Amount"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="SpentDownAmount"/>
<display value="Spent Down Amount"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="CoverageGap"/>
<display value="Coverage Gap"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<authorizationRequired value="true"/>
<authorizationSupporting>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-authorization-supporting"/>
<code value="form"/>
<display value="Form"/>
</coding>
</authorizationSupporting>
</item>
<item>
<productOrService>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service"/>
<code value="billing"/>
<display value="Billing Code"/>
</coding>
</productOrService>
<unit>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-insurance-unit"/>
<code value="family"/>
<display value="Family"/>
</coding>
</unit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="deductible"/>
<display value="deductible"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="OOPMax"/>
<display value="OOP Max"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="MaxBenefit/Year"/>
<display value="Max Benefit/Year"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
<usedMoney>
<value value="25"/>
<currency value="USD"/>
</usedMoney>
</benefit>
</item>
<item>
<productOrService>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-service"/>
<code value="billing"/>
<display value="Billing Code"/>
</coding>
</productOrService>
<network>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
<code value="in"/>
<display value="In Network"/>
</coding>
</network>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DrugCo-Pay"/>
<display value="Drug Co-Pay"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="SpecialistCo-Pay"/>
<display value="Specialist Co-Pay"/>
</coding>
</type>
<allowedMoney>
<value value="25"/>
<currency value="USD"/>
</allowedMoney>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-benefit-type"/>
<code value="DeductibleApplyOOP"/>
<display value="Does Deductible Apply to OOP"/>
</coding>
</type>
<allowedString value="Yes"/>
</benefit>
</item>
</insurance>
</CoverageEligibilityResponse>
</resource>
</entry>
</Bundle>