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
<Bundle xmlns="http://hl7.org/fhir">
<id value="uapi-copay-search-response-2"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-query-response-multi-patient"/>
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<identifier>
<use value="usual"/>
<system value="http://connectiverx.com/requestId"/>
<value value="86a42a99-663b-48b8-8fd9-c1afdbca5b98"/>
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<type value="message"/>
<timestamp value="2023-04-26T08:10:17-05:00"/>
<total value="2"/>
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<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: MessageHeader</b><a name="bbcef4fb-f0ee-4171-8b34-0d8f7b4b8743"> </a></p><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">Resource MessageHeader "bbcef4fb-f0ee-4171-8b34-0d8f7b4b8743" </p></div><p><b>event</b>: Copay Search Response (Details: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type code copay-search-resp = 'copay-search-resp', stated as 'Copay Search Response')</p><h3>Sources</h3><table class="grid"><tr><td>-</td><td><b>Name</b></td><td><b>Endpoint</b></td></tr><tr><td>*</td><td>Genentech-FHIR-DEV</td><td><a href="https://fhir.developer.gene.com/copay-search">https://fhir.developer.gene.com/copay-search</a></td></tr></table><h3>Responses</h3><table class="grid"><tr><td>-</td><td><b>Identifier</b></td><td><b>Code</b></td></tr><tr><td>*</td><td>1-63c61a26-4965b3a156f488da6e0800ed</td><td>ok</td></tr></table><p><b>focus</b>: <a href="#Parameters_4c2bc01b-7a3e-4856-a698-393e4aeda1cd">See above (urn:uuid:4c2bc01b-7a3e-4856-a698-393e4aeda1cd)</a></p></div>
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<eventCoding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type"/>
<code value="copay-search-resp"/>
<display value="Copay Search Response"/>
</eventCoding>
<source>
<name value="Genentech-FHIR-DEV"/>
<endpoint value="https://fhir.developer.gene.com/copay-search"/>
</source>
<response>
<identifier value="1-63c61a26-4965b3a156f488da6e0800ed"/>
<code value="ok"/>
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<focus>
<reference value="urn:uuid:4c2bc01b-7a3e-4856-a698-393e4aeda1cd"/>
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<entry>
<fullUrl value="urn:uuid:4c2bc01b-7a3e-4856-a698-393e4aeda1cd"/>
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<Parameters>
<id value="4c2bc01b-7a3e-4856-a698-393e4aeda1cd"/>
<parameter>
<name value="responder-page-index"/>
<valueInteger value="0"/>
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<parameter>
<name value="responder-page-size"/>
<valueInteger value="10"/>
</parameter>
<parameter>
<name value="search-result"/>
<valueReference>
<reference value="urn:uuid:981dc64a-2f66-4f1f-9963-0f991b47ce0b"/>
</valueReference>
</parameter>
<parameter>
<name value="search-result"/>
<valueReference>
<reference value="urn:uuid:392ffecb-41a5-4195-af3a-7c29927041f5"/>
</valueReference>
</parameter>
</Parameters>
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</entry>
<entry>
<fullUrl value="urn:uuid:981dc64a-2f66-4f1f-9963-0f991b47ce0b"/>
<resource>
<Bundle>
<id value="patient1-search-result-patient"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result-patient"/>
</meta>
<type value="searchset"/>
<timestamp value="2023-04-26T08:10:17-05:00"/>
<link>
<relation value="self"/>
<url value="Patient?given=Ti&family=Michaelson"/>
</link>
<entry>
<fullUrl value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<resource>
<Patient>
<id value="f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-patient"/>
</meta>
<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://connectiverx.com/confirmationId"/>
<value value="8132413049"/>
<assigner>
<display value="CRX"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Michaelson"/>
<given value="Timothy"/>
</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>
<managingOrganization>
<reference
value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
</managingOrganization>
</Patient>
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<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>
<identifier>
<use value="usual"/>
<system value="http://vendor.com/ab"/>
<value value="HOSP-12345"/>
<assigner>
<display value="AB Vendor"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Mid Atlantic Retina"/>
<telecom>
<system value="email"/>
<value value="mar@example.com"/>
</telecom>
<address>
<line value="8 Ranoldo Terrace"/>
<city value="Cherry Hill"/>
<state value="NJ"/>
<postalCode value="08034"/>
<country value="US"/>
</address>
<contact>
<name>
<use value="official"/>
<family value="Yardav"/>
<given value="Venus"/>
</name>
<telecom>
<system value="phone"/>
<value value="8882704882"/>
<use value="work"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="fax"/>
<value value="8179974042"/>
<use value="work"/>
<rank value="2"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:a7542e8a-760c-4b32-8941-ba3c0752680d"/>
<resource>
<Bundle>
<id value="a7542e8a-760c-4b32-8941-ba3c0752680d"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url
value="ExplanationOfBenefit?patient=xyz&_include=ExplanationOfBenefit:coverage&_include=ExplanationOfBenefit:provider"/>
</link>
<entry>
<fullUrl
value="urn:uuid:e344813d-eb60-466e-806b-ebd35c988293"/>
<resource>
<ExplanationOfBenefit>
<id value="e344813d-eb60-466e-806b-ebd35c988293"/>
<contained>
<OperationOutcome>
<id value="5ce061a8-302e-4135-a300-f68c73f31100"/>
<issue>
<severity value="error"/>
<code value="processing"/>
<details>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-copay-enrollment-error"/>
<code value="identification-check"/>
<display value="Identification Check"/>
</coding>
<text
value="Provided patient information does not meet minimum criteria for verification."/>
</details>
</issue>
</OperationOutcome>
</contained>
<identifier>
<use value="usual"/>
<system value="http://connectiverx.com/enrollmentId"/>
<value value="ad44f19a-42b6-ed11-827c-9e11af077484"/>
</identifier>
<status value="cancelled"/>
<type>
<coding>
<code value="institutional"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference
value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
</patient>
<created value="2023-04-11T21:01:11.230Z"/>
<insurer>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<outcome value="error"/>
<insurance>
<focal value="false"/>
<coverage>
<reference
value="urn:uuid:e6e8d8c6-a074-4ea5-be1a-a67cb8628a85"/>
</coverage>
</insurance>
</ExplanationOfBenefit>
</resource>
<search>
<mode value="match"/>
</search>
</entry>
<entry>
<fullUrl
value="urn:uuid:e6e8d8c6-a074-4ea5-be1a-a67cb8628a85"/>
<resource>
<Coverage>
<id value="e6e8d8c6-a074-4ea5-be1a-a67cb8628a85"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<status value="cancelled"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="pay"/>
<display value="Pay"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<type value="Patient"/>
</subscriber>
<beneficiary>
<reference
value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<type value="Patient"/>
</beneficiary>
<payor>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Vabysmo-Drug"/>
<name value="Ophthalmology Co Pay program"/>
</class>
<order value="1"/>
<network value="Genentech"/>
</Coverage>
</resource>
<search>
<mode value="include"/>
</search>
</entry>
<entry>
<fullUrl
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
<resource>
<Practitioner>
<id value="695d0991-5e03-46df-934a-85a28acd95c1"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"/>
</meta>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PRN"/>
<display value="Provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1922071448"/>
<assigner>
<display
value="Centers for Medicare & Medicaid Services"/>
</assigner>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
<display value="Tax ID number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="00000000"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1639285034"/>
</identifier>
<name>
<use value="official"/>
<family value="CRUZ"/>
<given value="MARISSA"/>
</name>
</Practitioner>
</resource>
<search>
<mode value="include"/>
</search>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:c712a56a-7cb2-449a-9bd0-edfda29966b6"/>
<resource>
<Bundle>
<id value="c712a56a-7cb2-449a-9bd0-edfda29966b6"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url value="Task?for=xyz"/>
</link>
<entry>
<fullUrl
value="urn:uuid:ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"/>
<resource>
<Task>
<id value="ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"/>
<status value="requested"/>
<intent value="plan"/>
<code>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-sr-type"/>
<code value="copay"/>
</coding>
</code>
<for>
<reference
value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<type value="Patient"/>
</for>
<authoredOn value="2023-01-23T08:10:13-05:00"/>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="9c2693fd-4eb2-4543-a26b-2c85a3450fe2"/>
</coding>
</valueCodeableConcept>
</input>
</Task>
</resource>
<search>
<mode value="match"/>
</search>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:6bccba21-8c51-4d73-8214-8b33a61fd193"/>
<resource>
<Bundle>
<id value="6bccba21-8c51-4d73-8214-8b33a61fd193"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url value="QuestionnaireResponse?subject=xyz"/>
</link>
<entry>
<fullUrl
value="urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a"/>
<resource>
<QuestionnaireResponse>
<id value="c29782b4-6ffc-494e-85ab-eee27bfd994a"/>
<questionnaire
value="https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234"/>
<status value="completed"/>
<subject>
<reference
value="urn:uuid:f7fe0b5e-538e-41df-955d-8b2be2c1d005"/>
<type value="Patient"/>
</subject>
<item>
<linkId value="consent-to-enroll"/>
<text
value="Does the patient consent to enroll in the Ocrevus Co-Pay Program?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="ocrevus-fda-approved-indications"/>
<text
value="Is the patient using OCREVUS for the following FDA-approved indications?"/>
<answer>
<valueCoding>
<code
value="Relapsing-forms-of-multiple-sclerosis-(MS),-to-include-clinically-isolated-syndrome,-relapsing-remitting-disease-and-active-secondary-progressive-disease-or-primary-progressive-forms-of-MS,-in-adults"/>
<display
value="Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="18-years-or-older"/>
<text value="Is the patient 18 years of age or older"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="commercial-private-insurance"/>
<text
value="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"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="federal-state-funded-insurance"/>
<text
value="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."/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="have-medicare-card"/>
<text
value="Does the patient have a Medicare (red, white and blue) card?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="enter-medicare-number"/>
<text value="Enter the Medicare number:"/>
<answer>
<valueString value="M577788"/>
</answer>
</item>
<item>
<linkId value="residence-state"/>
<text value="What state does the patient live in?"/>
<answer>
<valueString value="CA"/>
</answer>
</item>
<item>
<linkId value="receiving-medication-from-gpf"/>
<text
value="Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId
value="receiving-assistance-from-charitable-organization"/>
<text
value="Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="agree-to-genentech-privacy-policy"/>
<text
value="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 Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus 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."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="agree-to-copay-program-terms"/>
<text
value="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."/>
</item>
<item>
<linkId value="agree-to-admin-copay-program-terms"/>
<text
value="The Administration 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 and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program.
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 administration of 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 costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, 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 administration fees 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. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of 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 administration claims with a date of service that precedes the Program enrollment 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 and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. 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."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="information-correct"/>
<text value="All information is correct?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
</QuestionnaireResponse>
</resource>
<search>
<mode value="match"/>
</search>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:392ffecb-41a5-4195-af3a-7c29927041f5"/>
<resource>
<Bundle>
<id value="patient2-search-result-patient"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result-patient"/>
</meta>
<type value="searchset"/>
<timestamp value="2023-04-26T08:10:17-05:00"/>
<link>
<relation value="self"/>
<url value="Patient?given=Ti&family=Michaelson"/>
</link>
<entry>
<fullUrl value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
<resource>
<Patient>
<id value="15916852-5c50-4d5f-bdda-8013f02e802b"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-patient"/>
</meta>
<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://connectiverx.com/confirmationId"/>
<value value="5122413478"/>
<assigner>
<display value="CRX"/>
</assigner>
</identifier>
<name>
<use value="official"/>
<family value="Michaelson"/>
<given value="Tim"/>
</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>
<managingOrganization>
<reference
value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
</managingOrganization>
</Patient>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
<resource>
<Organization>
<id value="01c31a2f-321d-4c6e-8349-206af8a88088"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-organization"/>
</meta>
<identifier>
<use value="usual"/>
<system value="http://vendor.com/ab"/>
<value value="HOSP-12345"/>
<assigner>
<display value="AB Vendor"/>
</assigner>
</identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/organization-type"/>
<code value="prov"/>
<display value="Healthcare Provider"/>
</coding>
</type>
<name value="Mid Atlantic Retina"/>
<telecom>
<system value="email"/>
<value value="mar@example.com"/>
</telecom>
<address>
<line value="8 Ranoldo Terrace"/>
<city value="Cherry Hill"/>
<state value="NJ"/>
<postalCode value="08034"/>
<country value="US"/>
</address>
<contact>
<name>
<use value="official"/>
<family value="Yardav"/>
<given value="Venus"/>
</name>
<telecom>
<system value="phone"/>
<value value="8882704882"/>
<use value="work"/>
<rank value="1"/>
</telecom>
<telecom>
<system value="fax"/>
<value value="8179974042"/>
<use value="work"/>
<rank value="2"/>
</telecom>
</contact>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:d2317c7e-82a0-461e-b12e-1418b5e956dc"/>
<resource>
<Bundle>
<id value="d2317c7e-82a0-461e-b12e-1418b5e956dc"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url
value="ExplanationOfBenefit?patient=xyz&_include=ExplanationOfBenefit:coverage&_include=ExplanationOfBenefit:provider"/>
</link>
<entry>
<fullUrl
value="urn:uuid:4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"/>
<resource>
<ExplanationOfBenefit>
<id value="4822ddcc-2ce7-4b43-b6af-4f3435ce5a6d"/>
<identifier>
<use value="usual"/>
<system value="http://connectiverx.com/enrollmentId"/>
<value value="45d1b98c-587c-ed11-8279-d6b6a2da4722"/>
</identifier>
<status value="active"/>
<type>
<coding>
<code value="pharmacy"/>
</coding>
</type>
<use value="predetermination"/>
<patient>
<reference
value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
</patient>
<created value="2023-02-07T08:10:13-05:00"/>
<insurer>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
</insurer>
<provider>
<reference
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
</provider>
<outcome value="complete"/>
<insurance>
<focal value="true"/>
<coverage>
<reference
value="urn:uuid:597540c9-6248-466e-81e0-58e78f15454e"/>
</coverage>
</insurance>
</ExplanationOfBenefit>
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<search>
<mode value="match"/>
</search>
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<entry>
<fullUrl
value="urn:uuid:597540c9-6248-466e-81e0-58e78f15454e"/>
<resource>
<Coverage>
<id value="597540c9-6248-466e-81e0-58e78f15454e"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-coverage"/>
</meta>
<extension
url="https://fhir.developer.gene.com/StructureDefinition/IssuedDate">
<valueDate value="2023-01-01"/>
</extension>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="pay"/>
<display value="Pay"/>
</coding>
</type>
<subscriber>
<reference
value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
<type value="Patient"/>
</subscriber>
<subscriberId value="EYE00044117"/>
<beneficiary>
<reference
value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
<type value="Patient"/>
</beneficiary>
<period>
<start value="2023-01-01"/>
<end value="2023-12-31"/>
</period>
<payor>
<reference
value="urn:uuid:d02db104-a75c-433f-8764-9778c2e20626"/>
<type value="Organization"/>
</payor>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxbin"/>
<display value="RX BIN"/>
</coding>
</type>
<value value="600426"/>
<name value="BIN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="rxpcn"/>
<display value="RX PCN"/>
</coding>
</type>
<value value="54"/>
<name value="PCN"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="group"/>
<display value="Group"/>
</coding>
</type>
<value value="EC38517002"/>
<name value="Group Number"/>
</class>
<class>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
<code value="plan"/>
<display value="Plan"/>
</coding>
</type>
<value value="Vabysmo-Drug"/>
<name value="Ophthalmology Co Pay program"/>
</class>
<order value="1"/>
<network value="Genentech"/>
</Coverage>
</resource>
<search>
<mode value="include"/>
</search>
</entry>
<entry>
<fullUrl
value="urn:uuid:695d0991-5e03-46df-934a-85a28acd95c1"/>
<resource>
<Practitioner>
<id value="695d0991-5e03-46df-934a-85a28acd95c1"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-practitioner"/>
</meta>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="PRN"/>
<display value="Provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1922071448"/>
<assigner>
<display
value="Centers for Medicare & Medicaid Services"/>
</assigner>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="TAX"/>
<display value="Tax ID number"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="00000000"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
</type>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1639285034"/>
</identifier>
<name>
<use value="official"/>
<family value="CRUZ"/>
<given value="MARISSA"/>
</name>
</Practitioner>
</resource>
<search>
<mode value="include"/>
</search>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:144bc1e8-ad84-4447-8bbf-f82a78cc0151"/>
<resource>
<Bundle>
<id value="144bc1e8-ad84-4447-8bbf-f82a78cc0151"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url value="Task?for=xyz"/>
</link>
<entry>
<fullUrl
value="urn:uuid:ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"/>
<resource>
<Task>
<id value="ea171b4a-3b8f-4ed9-8488-6bb1242c6c7a"/>
<status value="requested"/>
<intent value="plan"/>
<code>
<coding>
<system
value="https://fhir.developer.gene.com/CodeSystem/uapi-sr-type"/>
<code value="copay"/>
</coding>
</code>
<for>
<reference
value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
<type value="Patient"/>
</for>
<authoredOn value="2023-01-23T08:10:13-05:00"/>
<input>
<type>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-task-input-type"/>
<code value="brandId"/>
</coding>
</type>
<valueCodeableConcept>
<coding>
<system
value="http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-copay-brand-id"/>
<code value="9c2693fd-4eb2-4543-a26b-2c85a3450fe2"/>
</coding>
</valueCodeableConcept>
</input>
</Task>
</resource>
<search>
<mode value="match"/>
</search>
</entry>
</Bundle>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:482ddd0b-93de-4b64-b64d-9fd4f5f77a4a"/>
<resource>
<Bundle>
<id value="482ddd0b-93de-4b64-b64d-9fd4f5f77a4a"/>
<meta>
<profile
value="https://fhir.developer.gene.com/StructureDefinition/uapi-bundle-search-result"/>
</meta>
<type value="searchset"/>
<total value="1"/>
<link>
<relation value="self"/>
<url value="QuestionnaireResponse?subject=xyz"/>
</link>
<entry>
<fullUrl
value="urn:uuid:c29782b4-6ffc-494e-85ab-eee27bfd994a"/>
<resource>
<QuestionnaireResponse>
<id value="c29782b4-6ffc-494e-85ab-eee27bfd994a"/>
<questionnaire
value="https://dev.gene.com/fhir/uapi/fhirapi/Questionnaire/1234"/>
<status value="completed"/>
<subject>
<reference
value="urn:uuid:15916852-5c50-4d5f-bdda-8013f02e802b"/>
<type value="Patient"/>
</subject>
<item>
<linkId value="consent-to-enroll"/>
<text
value="Does the patient consent to enroll in the Ocrevus Co-Pay Program?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="ocrevus-fda-approved-indications"/>
<text
value="Is the patient using OCREVUS for the following FDA-approved indications?"/>
<answer>
<valueCoding>
<code
value="Relapsing-forms-of-multiple-sclerosis-(MS),-to-include-clinically-isolated-syndrome,-relapsing-remitting-disease-and-active-secondary-progressive-disease-or-primary-progressive-forms-of-MS,-in-adults"/>
<display
value="Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease or primary progressive forms of MS, in adults"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="18-years-or-older"/>
<text value="Is the patient 18 years of age or older"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="commercial-private-insurance"/>
<text
value="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"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="federal-state-funded-insurance"/>
<text
value="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."/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="have-medicare-card"/>
<text
value="Does the patient have a Medicare (red, white and blue) card?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
<item>
<linkId value="enter-medicare-number"/>
<text value="Enter the Medicare number:"/>
<answer>
<valueString value="M577788"/>
</answer>
</item>
<item>
<linkId value="residence-state"/>
<text value="What state does the patient live in?"/>
<answer>
<valueString value="CA"/>
</answer>
</item>
<item>
<linkId value="receiving-medication-from-gpf"/>
<text
value="Is the patient currently receiving Ocrevus from the Genentech Patient Foundation?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId
value="receiving-assistance-from-charitable-organization"/>
<text
value="Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the Ocrevus Co-pay Program?"/>
<answer>
<valueString value="No"/>
</answer>
</item>
<item>
<linkId value="agree-to-genentech-privacy-policy"/>
<text
value="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 Ocrevus Co-pay Program. The patient agrees to be contacted by phone, mail or email about the Ocrevus 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."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="agree-to-copay-program-terms"/>
<text
value="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."/>
</item>
<item>
<linkId value="agree-to-admin-copay-program-terms"/>
<text
value="The Administration 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 and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program.
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 administration of 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 costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, 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 administration fees 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. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of 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 administration claims with a date of service that precedes the Program enrollment 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 and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. 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."/>
<answer>
<valueString value="Agree"/>
</answer>
</item>
<item>
<linkId value="information-correct"/>
<text value="All information is correct?"/>
<answer>
<valueString value="Yes"/>
</answer>
</item>
</QuestionnaireResponse>
</resource>
<search>
<mode value="match"/>
</search>
</entry>
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</resource>
</entry>
</Bundle>
</resource>
</entry>
</Bundle>
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