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
The purpose of a status query is for the client to obtain on behalf of an HCP the:
A Status Query FHIR bundle consists of:
To create a Status Query Request bundle, use the mapping tables below AND your enrollment bundle for reference. Please refer to the Systematic Queries page for additional information.
| Row | Resource - Element | Required or Optional | Accepted Values | Description |
|---|---|---|---|---|
| 1 | MessageHeader.sender.identifier.use | Required | "usual" | |
| 2 | MessageHeader.sender.identifier.system | Required | url or IP address for HCP office. This should be the name of the practice.<br Example: http://practicename.com/ |
|
| 3 | MessageHeader.sender.identifier.value | Required | HCP identifier; has to be exact identifier used in enrollment bundle or else, Genentech will not be able to locate the correct patient aligned to HCP practice. Refer to enrollment bundle: Organization.identifier.value [where code= 'prov'] |
|
| 4 | MessageHeader.source.name | Required | name of the client that is submitting on behalf of the HCP. This is the same 'source' name provided in the enrollment bundle. | |
| 5 | MessageHeader.source.endpoint | Required | url or IP address for client. Example: "http://vendorname.com" |
|
| 6 | MessageHeader.focus.reference | Required | the same uuid found in Parameters resource | |
| 7 | Parameters.parameter.valuereference.identifier.use [where name= 'requestor-patient'] |
Required | "official" | |
| 8 | Parameters.parameter.valuereference.identifier.system [where name= 'requestor-patient'] |
Required | same url or IP address for HCP office found in MessageHeader.sender.identifier.system (where type= 'Organization') |
|
| 9 | Parameters.parameter.value [where name= 'requestor-patient'] |
Required | This is the same patient identifier provided by HCP or client in the enrollment bundle: Patient.identifer.value (where code= 'PI') |
|
| 10 | Parameters.parameter.assigner.display [where name= 'requestor-patient'] |
Required | for assigner.display enter the name of the client | |
| 11 | Parameters.parameter.valuereference.reference [where name= 'requestor-servicerequest'] |
Optional | Optional; provide to help narrow down search | |
| 12 | Parameters.parameter.valuereference.identifier.value [where name= '"requester-bundle-enrollment-id'] |
Optional | Optional; provide enrollment-Id to help narrow patient search. The same transaction ID provided in the enrollment bundle or received after enrollment bundle is submitted. |
|
| 13 | Parameters.parameter.valuestring [where name= '"query-string'] |
Required | "CoverageEligibilityResponse?status=active" | |
| 14 | ServiceRequest.status | Optional | "active" | Service Request is Optional; provide to help narrow down search Required only if ServiceRequest resource is included in bundle |
| 15 | ServiceRequest.intent | Optional | "order" | Service Request is Optional; provide to help narrow down search Required only if ServiceRequest resource is included in bundle |
| 16 | ServiceRequest.code.coding.code | Optional | -"bipa" -"patient foundation" -"gpf" |
Service Request is Optional; provide to help narrow down search Required only if ServiceRequest resource is included in bundle |
| 17 | ServiceRequest.subject.reference [where subject= 'patient'] |
Optional | Service Request is Optional; provide to help narrow down search Required only if ServiceRequest resource is included in bundle |
Sample Status Query Request Bundle
| Row | Eligibility Details | Accepted Values | FHIR Field/Element | Description |
|---|---|---|---|---|
| 1 | Patient Foundation Shipment Method | -Upfront -Replacement |
CoverageEligibilityResponse.extension.valuestring [where url: http://dev.gene.com/fhir/uapi/StructureDefinition/gpf-shipment-method] |
Refer to "Products Specific" page (section 11.2) to find which shipment method is available for each product |
| 2 | Patient Foundation Eligibility Status | -Approved -Denied -Approved (Exception) -Inconclusive |
CoverageEligibilityResponse.extension.valuestring [where url: http://dev.gene.com/fhir/uapi/StructureDefinition/Outcome] |
|
| 3 | Approval Date | CoverageEligibilityResponse.servicedDate | When Eligibility Status = Approved or Approved (exception), then the Approval Date is displayed | |
| 4 | Denial Date | CoverageEligibilityResponse.servicedDate | When Eligibility Status = Denied, then the Denial Date is displayed | |
| 5 | Eligibility Reason | -No Insurance -Insured: No Coverage for Medication -Insured: Can't afford Medication |
CoverageEligibilityResponse.disposition | |
| 6 | MPAT | Patient.identifier.value [where "system": "http://gene.com/patientmaster"] |
Master Patient # assigned by Access Solutions/Patient Foundation | |
| 7 | Patient ID | Patient.identifier.value [where "system": "http://gene.com/patient"] |
Practice Patient# assigned by Access Solutions/Patient Foundation | |
| 8 | Patient ID (HCP assigned patient# provided in the query) | Patient.identifier.value [where "system" is the same HCP system url provided in the query] |
the value should be the same HCP patient id value provided in the query | |
| 9 | Patient Name | Patient.name.family Patient.name.given | Patient name should match the patient that was being queried | |
| 10 | Patient Birthdate | Patient.birthDate | Patient DOB should match HCP records |
Sample Status Query Response bundle for GPF
| Benefits Investigation Outcome | FHIR Resource Element | Expected Values | Comments |
|---|---|---|---|
| Service Request | CoverageEligibilityResponse.identifier where"system": "https://genentech-pps.my.salesforce.com/Case" | ||
| PatientID | Patient.identifier.value where "code": "PI" | ||
| Patient FirstName | Patient.name.given | ||
| Patient LastName | Patient.name.family | ||
| Patient DOB | Patient.birthDate | ||
| Drug | CoverageEligibilityRequest.extension.valueCodeableCode.coding where "system": "https://fhir.developer.gene.com/CodeSystem/uapi-product-name" | displayed on New BI version | |
| ICD10 / Diagnosis Code | CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConce | ||
| ICD10 / Diagnosis Code | CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept | ||
| ICD10 / Diagnosis Code | CoverageEligibilityRequest.item.diagnosis.diagnosisCodeableConcept | ||
| Notes | CoverageEligibilityResponse.extension.valueCodeableConcept.coding.code where "url": "http://gene.com/fhir/uapi/StructureDefinition/billingInstructions" | ||
| Notes | CoverageEligibilityResponse.extension.valueCodeableConcept.coding.code where "url": "http://gene.com/fhir/uapi/StructureDefinition/benefitsSummary" | ||
| Name (Payer Name) | Organization.name where type.coding.code= 'ins' contained under CoverageEligibilityResponse | ||
| Plan Product | Coverage.class.type.coding.code (where display= SubPlan) contained under CoverageEligibilityResponse | CHAMPVA EPO FEP HMO Indemnity Managed Medicaid MA-PD Medicare Advantage (Part C) Medicare Part A Medicare Part B Medicare Part D Medicare Supplemental Not Health Insurance POS PPO Prescription State Medicaid TRICARE VA |
|
| Plan Type | Coverage.class.type.coding.code (where display= Plan) contained under CoverageEligibilityResponse |
Commercial State Medicaid Medicare Healthcare Marketplace |
|
| Subscriber ID | Coverage.subscriberId contained under CoverageEligibilityResponse |
||
| Group Number | Coverage.class.type.coding.code(group) contained under CoverageEligibilityResponse |
||
| Effective Date | Coverage.period.start contained under CoverageEligibilityResponse | ||
| Eligibility Period | Coverage.extension.valuestring where "url" : "https://fhir.developer.gene.com/StructureDefinition/PlanYear" contained under CoverageEligibilityResponse |
Calendar Year Calendar Monthly Calendar Quarterly Benefit Year Benefit Monthly Benefit Quarterly |
|
| Payer Phone | Organization.contact.telecom contained under CoverageEligibilityResponse | ||
| Payer contact | Organization.contact contained under CoverageEligibilityResponse | ||
| Reference Number | Coverage.extension.valueString where "url": "http://gene.com/fhir/uapi/StructureDefinition/ReferenceNumber" contained under CoverageEligibilityResponse | ||
| BI Obtained Date | PENDING | ||
| Benefit Type | CoverageEligibilityResponse.insurance.item.benefit.type (?) | Major Medical In Office ASC HOPD Home Infusion Home Injection Self Injection Mail Order Retail/RX |
|
| Product Coverage | CoverageEligibilityResponse.disposition | Yes, if medically necessary No |
|
| Product Coverage | CoverageEligibilityResponse.insurance.item.network.coding where "system": "http://terminology.hl7.org/CodeSystem/benefit-network" | In Network Out of Network |
|
| Billing Code | CoverageEligibilityResponse.insurance.item.productOrService.coding.code = "billing" where "system": "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-product-jcode" |
||
| Billing Code: Prior Auth | CoverageEligibilityResponse.Insurance.item.authorizationRequired | Yes No |
|
| Billing Code: PreD Required | CoverageEligibilityResponse (?) | Required Highly Recommended Voluntary |
|
| Admin Code | CoverageEligibilityResponse.insurance.productOrService.text where coding.code = admin |
||
| Admin Code | CoverageEligibilityResponse.insurance.item.productOrService.text where coding.code = admin |
||
| Admin Code: Prior Auth/PreD Required | CoverageEligibilityResponse (?) | Yes No |
|
| Prior Authorization Phone | Organization.contact.telecom contained under CoverageEligibilityResponse | ||
| Prior Authorization Fax | Organization.contact.telecom contained under CoverageEligibilityResponse | ||
| Prior Authorization Online | Organization.extension.valuestring(url: "PA Payer Link") contained under CoverageEligibilityResponse | ||
| Individual Deductible | CoverageEligibilityResponse.insurance item.unit.coding.code = "individual" item.benefit.type.coding.code = "deductible" item.benefit.type.allowedMoney |
||
| Individual Deductible Met | CoverageEligibilityResponse.insurance item.unit.coding.code = "individual" item.benefit.type.coding.code = "deductible" item.benefit.type.usedMoney |
||
| Individual Out of Pocket Max | CoverageEligibilityResponse.insurance item.unit.coding.code = "individual" item.benefit.type.coding.code = "OOP Max" item.benefit.type.allowedMoney |
||
| Individual Out of Pocket Max Met | CoverageEligibilityResponse.insurance item.unit.coding.code = "individual" item.benefit.type.coding.code = "OOP Max" item.benefit.type.usedMoney |
||
| Family Deductible | CoverageEligibilityResponse.insurance item.unit.coding.code = "family" item.benefit.type.coding.code = "deductible" item.benefit.type.allowedMoney |
||
| Family Deductible Met | CoverageEligibilityResponse.insurance item.unit.coding.code = "family" item.benefit.type.coding.code = "deductible" item.benefit.type.usedMoney |
||
| Family Out of Pocket Max | CoverageEligibilityResponse.insurance item.unit.coding.code = "family" item.benefit.type.coding.code = "OOP Max" item.benefit.type.allowedMoney |
||
| Family Out of Pocket Max Met | CoverageEligibilityResponse.insurance item.unit.coding.code = "family" item.benefit.type.coding.code = "OOP Max" item.benefit.type.usedMoney |
||
| Insurer Cost Share | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "InsurerCostShare" item.benefit.allowedString |
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| Patient Cost Share | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "PatientCostShare" item.benefit.allowedString |
||
| Drug Co-Pay | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "DrugCo-Pay" item.benefit.allowedMoney |
||
| Specialist Co-pay | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "SpecialistCo-Pay" item.benefit.allowedMoney |
||
| Place of Service Co-pay | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "PlaceOfService_Co-Pay" item.benefit.allowedMoney |
||
| Deductible(s) Applies to Out of Pocket Max | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "Does Deductible Apply to OOP" item.benefit.allowedString |
No Yes |
|
| Annual Benefit Max | CoverageEligibilityResponse.insurance item.unit.coding.code = "individual" item.benefit.type.coding.code = "MaxBenefit/Year" item.benefit.allowedMoney |
||
| Buy and Bill | CoverageEligibilityResponse.insurance item.benefit.type.coding.code = "BuyBill" item.benefit.allowedString |
Available Required Not Available |
|
| Specialty Pharmacy | CoverageEligibilityResponse.extension.valueCodeableConcept.coding.code where "system": "http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-specialty-pharmacy" |
Available Required Not Available |
|
| Specialty Pharmacy 1 / Specialty Pharmacy 2: | Organization.name where type.coding.code= 'other' contained under CoverageEligibilityResponse |
||
| Specialty Phone 1 / Specialty Phone 2: | Organization.contact.telecom contained under CoverageEligibilityResponse |
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| Specialty Fax 1 / Specialty Fax 2: | Organization.contact.telecom contained under CoverageEligibilityResponse |