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

Services

Applicable for Use Case(s):

• Prescriber Service with Patient Consent
  
• Prescriber Service Only
  
• Patient Consent Only
  

Services Offered

Access Solutions offers the following services and each service is intended to be selected a la carte. All services offered are not inclusive to the enrollment.

1)Benefits Investigation/Prior Authorization (bipa)
Access Solutions can conduct a benefits investigation (BI) to help you determine if a Genentech medicine is covered, if prior authorizations (PAs) are required, which specialty pharmacy (SP) the health insurance plan prefers and if patient assistance might be needed.
Potential outcomes of a BI:

• Treatment is covered
• PA is required
• Treatment is denied

​Example of biPA Enrollment

2) Referral for Copay Assistance Service Request (copay)

Genentech medicine-specific co-pay programs provide financial assistance to eligible commercially insured patients to help with their co-pays, co-insurance or other out-of-pocket costs. Eligible patients must have commercial insurance; must not have Medicare, Medicaid or other government insurance; and must meet other criteria. They must agree to the rules set forth in the terms and conditions for the program. For eligible patients with commercial or public health insurance, Access Solutions will offer referrals to independent co-pay assistance foundations.

Note: The Referral for CoPay Assistance Service Request administered by Access Solutions is different from the CoPay Card program administered by Connective RX.

Example of Copay Enrollment

3) Starter Program (starter)

Access Solutions offers Starter Program kits for several products (refer to Genentech Products table under Prescriptions section). If eligible, allows patients to start treatment during the reimbursement process. Starter Program services are available only for the following products:

• Evrysdi
• Venclexta
• Xolair
• Ocrevus Zunovo

​Example of Starter Enrollment

4) Genentech Patient Foundation (patient foundation)

The Genentech Patient Foundation gives free Genentech medicine to people who don’t have insurance coverage or who have financial concerns and meet certain eligibility criteria. Learn more about the Genentech Patient Foundation.

​Example of GPF Enrollment

5) Appeals Support (appeal)

If a patient’s health insurance plan has issued a denial, Access Solutions can help provide resources to prepare an appeal submission, as per the patient’s plan requirements.

Example of Appeals Enrollment

Technical Implementation of Service Requests

​The services must be selected within the FHIR bundle. Specific services are defined by including them in the bundle.entry[i] array (see UAPI AS Enrollment Bundle profile) as ServiceRequest FHIR resources with corresponding types. See full bundle example here. See ServiceRequest code snippet in Enrollment bundle below where both biPA and starter services are requested:

{
  "resourceType" : "Bundle",
  "id" : "b17e292b-aef1-4e64-90c2-2d01f809041a",

  (...) // more code...
  
  "type" : "message",
  "timestamp" : "2020-03-11T08:10:13-05:00",
  "entry" : [
  {
      "fullUrl" : "urn:uuid:212c57ad-45cd-4882-87e7-8415ded3db05",
      "resource" : {
        "resourceType" : "ServiceRequest",
        "id" : "212c57ad-45cd-4882-87e7-8415ded3db05",
        "meta" : {
          "profile" : [
            "http://dev.gene.com/fhir/uapi/StructureDefinition/uapi-servicerequest"
          ]
        },
        "status" : "active",
        "intent" : "order",
        "code" : {
          "coding" : [
            {
              "system" : "http://dev.gene.com/fhir/uapi/CodeSystem/uapi-sr-type",
              "code" : "biPA"
            }
          ]
        },
        "subject" : {
          "reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
          "type" : "Patient"
        }
      }
    },
    {
      "fullUrl" : "urn:uuid:1409c0e9-6b06-4de5-82e7-577516c866db",
      "resource" : {
        "resourceType" : "ServiceRequest",
        "id" : "1409c0e9-6b06-4de5-82e7-577516c866db",
        "meta" : {
          "profile" : [
            "http://dev.gene.com/fhir/uapi/StructureDefinition/uapi-servicerequest"
          ]
        },
        "status" : "active",
        "intent" : "order",
        "code" : {
          "coding" : [
            {
              "system" : "http://dev.gene.com/fhir/uapi/CodeSystem/uapi-sr-type",
              "code" : "starter"
            }
          ]
        },
        "subject" : {
          "reference" : "urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c",
          "type" : "Patient"
        }
      }
    },

    (...) more code...

    ]
}

Site of Treatment

This is the location of where the therapy will be administered. If the patient will be treated at a site other than the referring Doctor’s office, then the site of treatment will need to be defined. This can include infusion centers, surgical centers, hospital outpatient to name a few.

Enrollment Bundle Elements Description

The below table describes how traditional enrollment elements (web-form or paper-form) translate to the corresponding FHIR Resources in this IG.