HL7.FHIR.US.CARIN-RTPBC\RTPBC Request Bundle submitted to a pricing source - XML Representation

This page is part of the Consumer Real-time Pharmacy Benefit Check (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
: RTPBC Request Bundle submitted to a pricing source - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="rtpbc-bundle-request-03-price-source"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-bundle"/>
  </meta>
  <type value="message"/>
  <timestamp value="2019-11-15T13:10:13-05:00"/>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a"/>
    <resource>
      <MessageHeader>
        <id value="rtpbc-messageheader-request-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-messageheader"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-messageheader-request-03</p><p><b>meta</b>: </p><p><b>event</b>: <span title="{http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type rtpbc-request}">RTPBC Request</span></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>MyPatientApp</td><td><a href="http://example.org/MyPatientApp">http://example.org/MyPatientApp</a></td></tr></table><p><b>focus</b>: <a href="#Claim_rtpbc-claim-03">See above (Claim/rtpbc-claim-03)</a></p><p><b>definition</b>: <a href="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-request">http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-request</a></p></div>
        </text>
        <eventCoding>
          <system
                  value="http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type"/>
          <code value="rtpbc-request"/>
          <display value="RTPBC Request"/>
        </eventCoding>
        <source>
          <name value="MyPatientApp"/>
          <endpoint value="http://example.org/MyPatientApp"/>
        </source>
        <focus>
          <reference value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b"/>
        </focus>
        <definition
                    value="http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-request"/>
      </MessageHeader>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b"/>
    <resource>
      <Claim>
        <id value="rtpbc-claim-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-claim-03</p><p><b>meta</b>: </p><p><b>identifier</b>: id: rtpbc-03</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type pharmacy}">Pharmacy</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href="#Patient_rtpbc-patient-03">See above (Patient/rtpbc-patient-03)</a></p><p><b>created</b>: Nov 1, 2019 4:20:54 PM</p><p><b>provider</b>: <a href="#Organization_rtpbc-organization-03">See above (Organization/rtpbc-organization-03)</a></p><p><b>priority</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><p><b>prescription</b>: <a href="#MedicationRequest_rtpbc-medicationrequest-03">See above (MedicationRequest/rtpbc-medicationrequest-03)</a></p><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href="#Practitioner_rtpbc-practitioner-03">See above (Practitioner/rtpbc-practitioner-03)</a></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><span></span></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>ProductOrService</b></td><td><b>Quantity</b></td></tr><tr><td>*</td><td>1</td><td>1</td><td><span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}">PROzac 10 MG Oral Capsule</span></td><td>60 {Each}</td></tr></table></div>
        </text>
        <identifier>
          <value value="rtpbc-03"/>
        </identifier>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
            <code value="pharmacy"/>
            <display value="Pharmacy"/>
          </coding>
        </type>
        <use value="predetermination"/>
        <patient>
          <reference value="Patient/rtpbc-patient-03"/>
        </patient>
        <created value="2019-11-01T11:20:54-05:00"/>
        <provider>
          <reference value="Organization/rtpbc-organization-03"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
            <display value="Normal"/>
          </coding>
        </priority>
        <prescription>
          <reference value="MedicationRequest/rtpbc-medicationrequest-03"/>
        </prescription>
        <careTeam>
          <sequence value="1"/>
          <provider>
            <reference value="Practitioner/rtpbc-practitioner-03"/>
          </provider>
        </careTeam>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <identifier>
              <value value="GOODPRICING"/>
            </identifier>
          </coverage>
        </insurance>
        <item>
          <sequence value="1"/>
          <careTeamSequence value="1"/>
          <productOrService>
            <coding>
              <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
              <code value="205535"/>
              <display value="PROzac 10 MG Oral Capsule"/>
            </coding>
          </productOrService>
          <quantity>
            <value value="60"/>
            <unit value="{Each}"/>
          </quantity>
        </item>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0c"/>
    <resource>
      <Patient>
        <id value="rtpbc-patient-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-patient-03</p><p><b>meta</b>: </p><p><b>identifier</b>: Patient internal identifier: 30455</p><p><b>name</b>: Jane Doe </p><p><b>gender</b>: female</p><p><b>birthDate</b>: 1975-12-05</p><p><b>address</b>: 100 Oak Court Madison WI 53510 US </p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
              <code value="PI"/>
              <display value="Patient internal identifier"/>
            </coding>
            <text value="Patient internal identifier"/>
          </type>
          <system value="http://example.org/MyPatientApp"/>
          <value value="30455"/>
        </identifier>
        <name>
          <family value="Doe"/>
          <given value="Jane"/>
        </name>
        <gender value="female"/>
        <birthDate value="1975-12-05"/>
        <address>
          <line value="100 Oak Court"/>
          <city value="Madison"/>
          <state value="WI"/>
          <postalCode value="53510"/>
          <country value="US"/>
        </address>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0e"/>
    <resource>
      <MedicationRequest>
        <id value="rtpbc-medicationrequest-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-medicationrequest-03</p><p><b>meta</b>: </p><p><b>status</b>: draft</p><p><b>intent</b>: proposal</p><p><b>reported</b>: true</p><p><b>medication</b>: <span title="Codes: {http://www.nlm.nih.gov/research/umls/rxnorm 205535}">PROzac 10 MG Oral Capsule</span></p><p><b>subject</b>: <a href="#Patient_rtpbc-patient-03">See above (Patient/rtpbc-patient-03)</a></p><p><b>authoredOn</b>: 2019-11-01</p><p><b>requester</b>: <a href="#Practitioner_rtpbc-practitioner-03">See above (Practitioner/rtpbc-practitioner-03)</a></p><p><b>dosageInstruction</b>: </p><h3>DispenseRequests</h3><table class="grid"><tr><td>-</td><td><b>Quantity</b></td><td><b>ExpectedSupplyDuration</b></td><td><b>Performer</b></td></tr><tr><td>*</td><td>60 {Each}</td><td>30 days</td><td><a href="#Organization_rtpbc-organization-03">See above (Organization/rtpbc-organization-03)</a></td></tr></table><h3>Substitutions</h3><table class="grid"><tr><td>-</td><td><b>Allowed[x]</b></td></tr><tr><td>*</td><td>false</td></tr></table></div>
        </text>
        <status value="draft"/>
        <intent value="proposal"/>
        <reportedBoolean value="true"/>
        <medicationCodeableConcept>
          <coding>
            <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
            <code value="205535"/>
            <display value="PROzac 10 MG Oral Capsule"/>
          </coding>
        </medicationCodeableConcept>
        <subject>
          <reference value="Patient/rtpbc-patient-03"/>
        </subject>
        <authoredOn value="2019-11-01"/>
        <requester>
          <reference value="Practitioner/rtpbc-practitioner-03"/>
        </requester>
        <dosageInstruction>
          <text value="Take 2 capsules once a day"/>
        </dosageInstruction>
        <dispenseRequest>
          <quantity>
            <value value="60"/>
            <unit value="{Each}"/>
          </quantity>
          <expectedSupplyDuration>
            <value value="30"/>
            <unit value="days"/>
            <system value="http://unitsofmeasure.org"/>
            <code value="d"/>
          </expectedSupplyDuration>
          <performer>
            <reference value="Organization/rtpbc-organization-03"/>
          </performer>
        </dispenseRequest>
        <substitution>
          <allowedBoolean value="false"/>
        </substitution>
      </MedicationRequest>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0f"/>
    <resource>
      <Practitioner>
        <id value="rtpbc-practitioner-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-practitioner-03</p><p><b>meta</b>: </p><p><b>identifier</b>: id: 1234567890</p><p><b>name</b>: Johnson </p></div>
        </text>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="1234567890"/>
        </identifier>
        <name>
          <family value="Johnson"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0g"/>
    <resource>
      <Organization>
        <id value="rtpbc-organization-03"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-organization-03</p><p><b>meta</b>: </p><p><b>identifier</b>: id: 9876543210</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes: {http://ncpdp.org/pharmacy-type R}">Retail</span></p><p><b>name</b>: Hometown Drug</p><p><b>telecom</b>: ph: 6081234567</p><p><b>address</b>: 900 9th Street Madison WI 53535 US </p></div>
        </text>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="9876543210"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system value="http://ncpdp.org/pharmacy-type"/>
            <code value="R"/>
            <display value="Retail"/>
          </coding>
        </type>
        <name value="Hometown Drug"/>
        <telecom>
          <system value="phone"/>
          <value value="6081234567"/>
        </telecom>
        <address>
          <line value="900 9th Street"/>
          <city value="Madison"/>
          <state value="WI"/>
          <postalCode value="53535"/>
          <country value="US"/>
        </address>
      </Organization>
    </resource>
  </entry>
</Bundle>