External - UAPI Copay Enrollment Bundle 2 with Combo Therapy - Universal API Implementation Guide v1.1.19

Universal API Implementation Guide
1.1.19 - ci-build

Universal API Implementation Guide - Local Development build (v1.1.19). See the Directory of published versions

Example Bundle: External - UAPI Copay Enrollment Bundle 2 with Combo Therapy

Bundle 7c8f5054-015b-4bce-99f5-4160a82a4225 of type message

Entry 1 - Full URL = urn:uuid:05621068-0e0b-4bc3-a0d0-d21f9270bcfd

Resource MessageHeader:

Generated Narrative: MessageHeader
Resource MessageHeader "05621068-0e0b-4bc3-a0d0-d21f9270bcfd"
Profile: UAPI MessageHeader
Texts
- Div
* <div></div>
UAPI MessageHeader Timestamp: 2020-03-11 08:10:13-0500
event: copay-enrollment (Details: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type code copay-enrollment = 'copay-enrollment', stated as 'null')
Destinations
- Name Endpoint
* UAPI-COPAY-ENR-V1.0 https://test-us-e1.apis.roche.com/pharma-cmg-copay-exp-test/v1/enroll
sender: See above (urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2)
Sources
- Name Endpoint
* Vendor_Tailormed http://vendor.com/fhir/enrollmentID/ENR-00001
focus: See above (urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0)

Entry 2 - Full URL = urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0

Resource List:

messageContext
Mode: Change List Status: Current
Items
urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c
urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2
urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f
urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330
urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20
urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a
urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df
urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311
urn:uuid:72d8daf1-f80f-4e56-bfcb-0558caf74feb
urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a

Entry 3 - Full URL = urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c

Resource Patient:

Ryan Michaelson (OFFICIAL) Male, DoB: 1972-10-29 ( Patient internal identifier: 6bcd8467-0473-4836-9128-2e7972f23177(use: USUAL))

Entry 4 - Full URL = urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2

Resource Organization:

Generated Narrative: Organization
Resource Organization "be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2"
Profile: UAPI Organization
Texts
- Div
* <div></div>
identifier: id: HOSP-12345(use: USUAL), National provider identifier: 1922071448(use: USUAL)
type: Healthcare Provider (OrganizationType#prov)
name: Cleveland Clinic
contact
telecom: ph: 8882704882(WORK)
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
contact
name: MARISSA CRUZ (OFFICIAL)
telecom: ph: -unknown-

Entry 5 - Full URL = urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f

Resource Organization:

Generated Narrative: Organization
Resource Organization "d3637025-883d-4678-9e0a-1d243a338f9f"
Profile: UAPI Organization
Texts
- Div
* <div></div>
identifier: id: PAY-111(use: USUAL)
type: Insurance Company (OrganizationType#ins)
name: Kaiser
Contacts
- Telecom
* ph: 8778472862(WORK)

Entry 6 - Full URL = urn:uuid:982e97af-668d-41ef-b9f9-2bbc4a059330

Resource Organization:

Generated Narrative: Organization
Resource Organization "982e97af-668d-41ef-b9f9-2bbc4a059330"
Profile: UAPI Organization
Texts
- Div
* <div></div>
identifier: id: PAY-145(use: USUAL)
type: Insurance Company (OrganizationType#ins)
name: CVS Specialty
contact
telecom: ph: -unknown-
contact
telecom: ph: 8778472862(WORK)

Entry 7 - Full URL = urn:uuid:cc31cf51-ea4f-4623-bdbb-2ea9e0068a20

Resource Practitioner:

Generated Narrative: Practitioner
Resource Practitioner "cc31cf51-ea4f-4623-bdbb-2ea9e0068a20"
Profile: UAPI Practitioner
Texts
- Div
* <div></div>
UAPI Practitioner Preferred Contact Method: work-phone (UAPI Code System - Prescriber Contact Methods#work-phone)
UAPI Practitioner Shipment Method: morning (UAPI Code System - Prescriber Contact Times#morning)
identifier: Provider identifier: 1922071448(use: OFFICIAL), National provider identifier: 1639285034(use: OFFICIAL)
name: MARISSA ANNE CRUZ (OFFICIAL)
telecom: ph: 8882704882(WORK), fax: 8882704883(WORK), prescribercopay@example.com
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US
Qualifications
- Code
* Doctor of Medicine (degreeLicenseCertificate#MD)

Entry 8 - Full URL = urn:uuid:984b9cae-45b0-407a-a682-11213a40a12f

Resource QuestionnaireResponse:

LinkId Text Definition Answer
984b9cae-45b0-407a-a682-11213a40a12f QuestionnaireResponse

consent-to-enroll Does the patient consent to enroll in the Genentech Oncology Co-Pay Program?

polivy-fda-approved-indications Is the patient using POLIVY™ (polatuzumab vedotin-piiq) for one of the following FDA-approved indications?

18-years-or-older Is the patient 18 years of age or older

commercial-private-insurance Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace

federal-state-funded-insurance Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.

have-medicare-card Does the patient have a Medicare (red, white and blue) card?

residence-state What state does the patient live in?

receiving-medication-from-gpf Is the patient currently receiving Polivy from the Genentech Patient Foundation?

receiving-assistance-from-charitable-organization Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Genentech Oncology Co-pay Program?

agree-to-genentech-privacy-policy The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and 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. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Genentech Oncology Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Genentech Oncology Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy.

agree-to-copay-program-terms 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.

polivy-combo-with-rituxan Is the patient on POLIVY in combination with RITUXAN® (rituximab)

polivy-receive-copay-for-rituxan Does the patient wish to receive Copay benefits for Rituxan as well

information-correct All information is correct?

assign-debitcard Do you require a 16-digit virtual card number to process the claim?

Documentation for this format

LinkId	Text	Definition
984b9cae-45b0-407a-a682-11213a40a12f		QuestionnaireResponse
consent-to-enroll	Does the patient consent to enroll in the Genentech Oncology Co-Pay Program?
polivy-fda-approved-indications	Is the patient using POLIVY™ (polatuzumab vedotin-piiq) for one of the following FDA-approved indications?
18-years-or-older	Is the patient 18 years of age or older
commercial-private-insurance	Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace
federal-state-funded-insurance	Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE.
have-medicare-card	Does the patient have a Medicare (red, white and blue) card?
residence-state	What state does the patient live in?
receiving-medication-from-gpf	Is the patient currently receiving Polivy from the Genentech Patient Foundation?
receiving-assistance-from-charitable-organization	Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Genentech Oncology Co-pay Program?
agree-to-genentech-privacy-policy	The patient acknowledges and agrees that any patient information disclosed during the enrollment, including contact information, demographic information, and information related to their medical condition, treatments, and health insurance and 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. The patient authorizes Genentech to receive, use, and share patient personal information in connection with the Genentech Oncology Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Genentech Oncology Co-pay Program. You have notified the patient that they can find more information in the Genentech Privacy Policy at www.gene.com/privacy-policy.
agree-to-copay-program-terms	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.
polivy-combo-with-rituxan	Is the patient on POLIVY in combination with RITUXAN® (rituximab)
polivy-receive-copay-for-rituxan	Does the patient wish to receive Copay benefits for Rituxan as well
information-correct	All information is correct?
assign-debitcard	Do you require a 16-digit virtual card number to process the claim?
Documentation for this format

Entry 9 - Full URL = urn:uuid:42b41bdb-1781-49aa-a091-78cdd92129df

Resource Coverage:

Generated Narrative: Coverage
Resource Coverage "42b41bdb-1781-49aa-a091-78cdd92129df"
Profile: UAPI Coverage
Texts
- Div
* <div></div>
status: ACTIVE
type: health insurance plan policy (ActCode#HIP)
subscriber: See above (urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a)
subscriberId: id: 4353
beneficiary: See above (urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c)
period: 2023-01-01 --> (ongoing)
class
type: RX BIN (Coverage Class Codes#rxbin)
value: id: K12345
name: BIN
class
type: RX PCN (Coverage Class Codes#rxpcn)
value: id: K234516
name: PCN
class
type: Group (Coverage Class Codes#group)
value: id: KAI2345
name: Group Number
class
type: Plan (Coverage Class Codes#plan)
value: id: HMO
name: Plan
order: 1
network: Kaiser

Entry 10 - Full URL = urn:uuid:d212ac11-903c-4040-a3d7-6b3e1874a311

Resource Coverage:

Generated Narrative: Coverage
Resource Coverage "d212ac11-903c-4040-a3d7-6b3e1874a311"
Profile: UAPI Coverage
Texts
- Div
* <div></div>
status: ACTIVE
type: drug policy (ActCode#DRUGPOL)
subscriber: See above (urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a)
subscriberId: id: 4353
beneficiary: See above (urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c)
period: 2023-01-01 --> (ongoing)
class
type: RX BIN (Coverage Class Codes#rxbin)
value: id: K3456
name: BIN
class
type: RX PCN (Coverage Class Codes#rxpcn)
value: id: K334455
name: PCN
class
type: Group (Coverage Class Codes#group)
value: id: KAI2345
name: Group Number
class
type: Plan (Coverage Class Codes#plan)
value: id: HMO
name: Plan
order: 1
network: CVS Specialty

Entry 11 - Full URL = urn:uuid:226e6ff9-9b26-4d4e-8e5e-e100770d6f4d

Resource Task:

Generated Narrative: Task
Resource Task "226e6ff9-9b26-4d4e-8e5e-e100770d6f4d"
Texts
- Div
* <div></div>
status: REQUESTED
intent: PLAN
code: Copay (UAPI Code System - Service Request Type#copay)
for: See above (urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c)
authoredOn: 2023-01-23 08:10:13-0500
requester: See above (urn:uuid:be7a688f-cdfd-41f4-9fe1-3e92abbfbbf2)
input
type: enroll-by-id (uapi-copay-task-input-type#enroll-by-id)
value: Patient (uapi-copay-enrollby-id#1)
input
type: brandId (uapi-copay-task-input-type#brandId)
value: 2195a20c-4cd6-47d2-8ff6-f458b89281f4 (uapi-copay-brand-id#2195a20c-4cd6-47d2-8ff6-f458b89281f4)
input
type: brandId (uapi-copay-task-input-type#brandId)
value: e36cda77-1c22-467a-b5fd-18ceddb6b023 (uapi-copay-brand-id#e36cda77-1c22-467a-b5fd-18ceddb6b023)

Entry 12 - Full URL = urn:uuid:12ed44e8-fde2-415d-9dcc-8e9117c73d2a

Resource RelatedPerson:

Generated Narrative: RelatedPerson
Resource RelatedPerson "12ed44e8-fde2-415d-9dcc-8e9117c73d2a"
Profile: UAPI RelatedPerson
Texts
- Div
* <div></div>
patient: See above (urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c)
relationship: significant other (RoleCode#SIGOTHR)
name: Bob Paul Smith (OFFICIAL)
telecom: ph: 310-462-1234(MOBILE)
birthDate: 1972-10-29
address: 8 Ranoldo Terrace Cherry Hill NJ 08034 US

IG © 2021+ . Package gene.com.fhir.uapi#1.1.19 based on FHIR 4.3.0. Generated 2024-02-19
Links: Table of Contents | QA Report