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-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"><p><b>Generated Narrative: MessageHeader</b><a name="5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa"> </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 "5c0cdcfa-4e39-4c4d-bff2-9d70a2f49eaa" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-messageheader.html">UAPI MessageHeader</a></p></div><p><b>event</b>: status-update (Details: http://terminology.gene.com/fhir/usix/uapi/CodeSystem/uapi-event-type code status-update = 'status-update', stated as 'null')</p><p><b>sender</b>: <a href="#Organization_01c31a2f-321d-4c6e-8349-206af8a88088">See above (urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088)</a></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-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="#List_8e055260-dd74-4c89-9ccf-3d2f47135ee0">See above (urn:uuid:8e055260-dd74-4c89-9ccf-3d2f47135ee0)</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"><p><b>Generated Narrative: List</b><a name="8e055260-dd74-4c89-9ccf-3d2f47135ee0"> </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 List "8e055260-dd74-4c89-9ccf-3d2f47135ee0" </p></div><p><b>status</b>: current</p><p><b>mode</b>: changes</p><p><b>title</b>: messageContext</p><blockquote><p><b>entry</b></p><p><b>item</b>: <a href="Bundle-uapi-query-response-1-gpf.html#urn-uuid-b3d46ea3-62e6-4171-b818-d64712edfe55">urn:uuid:b3d46ea3-62e6-4171-b818-d64712edfe55</a></p></blockquote><blockquote><p><b>entry</b></p><p><b>item</b>: <a href="#Organization_01c31a2f-321d-4c6e-8349-206af8a88088">See above (urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088)</a></p></blockquote><blockquote><p><b>entry</b></p><p><b>item</b>: <a href="#CoverageEligibilityRequest_a0e6a72c-a35b-4e1c-890e-6d34ed51d4de">See above (urn:uuid:a0e6a72c-a35b-4e1c-890e-6d34ed51d4de)</a></p></blockquote><blockquote><p><b>entry</b></p><p><b>item</b>: <a href="#CoverageEligibilityResponse_e89b0285-4582-4b1b-a448-f2cc467664f4">See above (urn:uuid:e89b0285-4582-4b1b-a448-f2cc467664f4)</a></p></blockquote><blockquote><p><b>entry</b></p><p><b>item</b>: <a href="#ClaimResponse_d8649c36-7586-4b5e-994a-3d6978227327">See above (urn:uuid:d8649c36-7586-4b5e-994a-3d6978227327)</a></p></blockquote></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>
<entry>
<item>
<reference value="urn:uuid:d8649c36-7586-4b5e-994a-3d6978227327"/>
<type value="ClaimResponse"/>
</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"><p><b>Generated Narrative: Organization</b><a name="01c31a2f-321d-4c6e-8349-206af8a88088"> </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 Organization "01c31a2f-321d-4c6e-8349-206af8a88088" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-organization.html">UAPI Organization</a></p></div><p><b>identifier</b>: id: HOSP-12345(use: USUAL), id: Vendor_AB_HOSP-12345(use: OFFICIAL)</p><p><b>type</b>: Healthcare Provider <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4B/codesystem-organization-type.html">OrganizationType</a>#prov)</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><h3>Contacts</h3><table class="grid"><tr><td>-</td><td><b>Name</b></td><td><b>Telecom</b></td></tr><tr><td>*</td><td>Venus Yardav (OFFICIAL)</td><td>ph: 8882704882(WORK), fax: 8179974042(WORK)</td></tr></table></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"><p><b>Generated Narrative: Patient</b><a name="7c0c0017-e08d-4a14-9889-9eea26303ff2"> </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 Patient "7c0c0017-e08d-4a14-9889-9eea26303ff2" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-uapi-patient.html">UAPI Patient</a></p></div><p><b>identifier</b>: Patient internal identifier: 540002(use: OFFICIAL), Patient internal identifier: MPAT-000123(use: USUAL)</p><p><b>name</b>: Ryan Michaelson (OFFICIAL)</p><p><b>telecom</b>: ph: 1231231234(HOME), ph: 1234561234(MOBILE), <a href="mailto:bobster83@example.com">bobster83@example.com</a></p><p><b>gender</b>: male</p><p><b>birthDate</b>: 1972-10-29</p><p><b>address</b>: 1234 Main St San Francisco CA 94105 US </p><h3>Communications</h3><table class="grid"><tr><td>-</td><td><b>Language</b></td><td><b>Preferred</b></td></tr><tr><td>*</td><td>English <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-v3-ietf3066.html">Tags for the Identification of Languages</a>#en)</span></td><td>true</td></tr></table><p><b>managingOrganization</b>: <a href="#Organization_01c31a2f-321d-4c6e-8349-206af8a88088">See above (urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088)</a></p></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"><p><b>Generated Narrative: CoverageEligibilityRequest</b><a name="a0e6a72c-a35b-4e1c-890e-6d34ed51d4de"> </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 CoverageEligibilityRequest "a0e6a72c-a35b-4e1c-890e-6d34ed51d4de" </p><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>: Benefit Investigation / Prior Authorization <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-uapi-sr-type.html">UAPI Code System - Service Request Type</a>#bipa)</span></p><p><b>UAPI CoverageEligibilityRequest Product</b>: Lucentis <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-uapi-product-name.html">UAPI Code System - Product Names</a>#lucentis)</span></p><p><b>identifier</b>: id: c78bde64-95e8-41f9-8a37-b2ac9aaf33d6(use: OLD), id: Lucentis-5001P00000maWeFQAU-(use: OFFICIAL)</p><p><b>status</b>: active</p><p><b>purpose</b>: benefits</p><p><b>patient</b>: <a href="#Patient_7c0c0017-e08d-4a14-9889-9eea26303ff2">See above (urn:uuid:7c0c0017-e08d-4a14-9889-9eea26303ff2)</a></p><p><b>created</b>: 2021-05-27 08:10:13-0500</p><p><b>provider</b>: <a href="#Organization_01c31a2f-321d-4c6e-8349-206af8a88088">See above (urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088)</a></p><p><b>insurer</b>: <a href="Bundle-caf568e0-21b6-40e4-b0b8-1fdddef30fd2.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f</a></p></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>
<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="official"/>
<system
value="https://genentech-pps.my.salesforce.com/Product-Case-Insurance"/>
<value value="Lucentis-5001P00000maWeFQAU-"/>
</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>
</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"><p><b>Generated Narrative: CoverageEligibilityResponse</b><a name="e89b0285-4582-4b1b-a448-f2cc467664f4"> </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 CoverageEligibilityResponse "e89b0285-4582-4b1b-a448-f2cc467664f4" </p><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>: Approved <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-uapi-coverage-outcome.html">UAPI Code System - CoverageEligibilityRequest outcome</a>#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>status</b>: active</p><p><b>purpose</b>: benefits</p><p><b>patient</b>: <a href="#Patient_7c0c0017-e08d-4a14-9889-9eea26303ff2">See above (urn:uuid:7c0c0017-e08d-4a14-9889-9eea26303ff2)</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="#CoverageEligibilityRequest_a0e6a72c-a35b-4e1c-890e-6d34ed51d4de">See above (urn:uuid:a0e6a72c-a35b-4e1c-890e-6d34ed51d4de)</a></p><p><b>outcome</b>: complete</p><p><b>disposition</b>: Yes, if medically necessary</p><p><b>insurer</b>: <a href="Bundle-caf568e0-21b6-40e4-b0b8-1fdddef30fd2.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f</a></p><blockquote><p><b>insurance</b></p><p><b>coverage</b>: <a name="42b41bdb-1781-49aa-a091-78cdd92129df"> </a></p><blockquote><p></p><p><a name="42b41bdb-1781-49aa-a091-78cdd92129df"> </a></p><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>: health insurance plan policy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-v3-ActCode.html">ActCode</a>#HIP)</span></p><p><b>subscriber</b>: <a href="Bundle-caf568e0-21b6-40e4-b0b8-1fdddef30fd2.html#urn-uuid-4db51d32-65c3-4f8c-959e-0155c6d14545">urn:uuid:4db51d32-65c3-4f8c-959e-0155c6d14545</a></p><p><b>subscriberId</b>: 4353</p><p><b>beneficiary</b>: <a href="Bundle-caf568e0-21b6-40e4-b0b8-1fdddef30fd2.html#urn-uuid-fc2e5a72-c363-4616-ae00-4ad25cbcb45c">urn:uuid:fc2e5a72-c363-4616-ae00-4ad25cbcb45c</a></p><p><b>period</b>: 2021-08-31 --> 2021-09-07</p><p><b>payor</b>: <a href="Bundle-caf568e0-21b6-40e4-b0b8-1fdddef30fd2.html#urn-uuid-d3637025-883d-4678-9e0a-1d243a338f9f">urn:uuid:d3637025-883d-4678-9e0a-1d243a338f9f</a></p><blockquote><p><b>class</b></p><p><b>type</b>: SubPlan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4B/codesystem-coverage-class.html">Coverage Class Codes</a>#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>: Plan <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4B/codesystem-coverage-class.html">Coverage Class Codes</a>#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>: Group <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4B/codesystem-coverage-class.html">Coverage Class Codes</a>#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><blockquote><p><b>item</b></p><p><b>productOrService</b>: Billing Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-product-service#billing)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Full BI <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#fullBI)</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Does Deductible Apply? <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DeductibleApply)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: does ind ded apply to family <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#doesIndDedApplyFamily)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Must Fam Ded Be Met Before Bene Cov <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#FamDedMetBefore)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Does OOP Apply <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#OOPApply)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Does Individual OOP Apply to Family <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#IndividualOOPFamily)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: 100% Cov only if Family OOP Met <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#100%Cov)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Insurer Cost Share % <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#InsurerCostShare)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Patient Cost Share % <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#PatientCostShare)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Buy and Bill <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#BuyBill)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Drug Tier Level <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DrugTierLevel)</span></p><p><b>allowed</b>: Yes</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Patient Cost Share % **Initial Coverage Stage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#PatientCostInitial)</span></p><p><b>allowed</b>: 25</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Day Supply **Initial Coverage Stage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DaysSupplyInitial)</span></p><p><b>allowed</b>: 30 day supply</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Drug Copay **Initial Coverage Stage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DrugCopayInitial)</span></p><p><b>allowed</b>: 30.00</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Patient Cost Share % **Catastrophic Coverage Stage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#PatientCostCatastrophic)</span></p><p><b>allowed</b>: 15</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: Drug Co-pay **Catastrophic Coverage Stage <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DrugCopayCatastrophic)</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>: Admin Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-product-service#admin)</span></p><p><b>unit</b>: Indivitual <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-insurance-unit#indivitual)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#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>: OOP MAx <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#OOPMax)</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>: Max Benefit/Year <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#MaxBenefit/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>: Max Lifetime Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#MaxLifetimeAmount)</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>: Spent Down Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#SpentDownAmount)</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>: Coverage Gap <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#CoverageGap)</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>: Form <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-authorization-supporting#form)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>productOrService</b>: Billing Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-product-service#billing)</span></p><p><b>unit</b>: Family <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-insurance-unit#family)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: deductible <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#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>: OOP Max <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#OOPMax)</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>: Max Benefit/Year <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#MaxBenefit/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>: Billing Code <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-product-service#billing)</span></p><p><b>network</b>: In Network <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R4B/codesystem-benefit-network.html">Network Type Codes</a>#in)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Drug Co-Pay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DrugCo-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>: Specialist Co-Pay <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#SpecialistCo-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>: Does Deductible Apply to OOP <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (uapi-benefit-type#DeductibleApplyOOP)</span></p><p><b>allowed</b>: Yes</p></blockquote></blockquote></blockquote></div>
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<allowedString value="Yes"/>
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<benefit>
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<system
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<code value="FamDedMetBefore"/>
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</coding>
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</coding>
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<allowedString value="Yes"/>
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<benefit>
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<system
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<display value="100% Cov only if Family OOP Met"/>
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<benefit>
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<coding>
<system
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</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>
<entry>
<fullUrl value="urn:uuid:d8649c36-7586-4b5e-994a-3d6978227327"/>
<resource>
<ClaimResponse>
<id value="d8649c36-7586-4b5e-994a-3d6978227327"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: ClaimResponse</b><a name="d8649c36-7586-4b5e-994a-3d6978227327"> </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 ClaimResponse "d8649c36-7586-4b5e-994a-3d6978227327" </p></div><p><b>status</b>: active</p><p><b>type</b>: pharmacy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> ()</span></p><p><b>use</b>: claim</p><p><b>patient</b>: <a href="Bundle-uapi-query-response-1-gpf.html#urn-uuid-b3d46ea3-62e6-4171-b818-d64712edfe55">urn:uuid:b3d46ea3-62e6-4171-b818-d64712edfe55</a></p><p><b>created</b>: 2021-05-27 08:10:13-0500</p><p><b>insurer</b>: <a href="#Organization_01c31a2f-321d-4c6e-8349-206af8a88088">See above (urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088)</a></p><p><b>outcome</b>: complete</p></div>
</text>
<status value="active"/>
<type>
<text value="pharmacy"/>
</type>
<use value="claim"/>
<patient>
<reference value="urn:uuid:b3d46ea3-62e6-4171-b818-d64712edfe55"/>
</patient>
<created value="2021-05-27T08:10:13-05:00"/>
<insurer>
<reference value="urn:uuid:01c31a2f-321d-4c6e-8349-206af8a88088"/>
</insurer>
<outcome value="complete"/>
</ClaimResponse>
</resource>
</entry>
</Bundle>
IG © 2021+ . Package gene.com.fhir.uapi#1.1.19 based on FHIR 4.3.0. Generated 2024-02-19
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