This page is part of the Consumer Real-time Pharmacy Benefit Check (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
JSON Format: Bundle-rtpbc-bundle-request-03
Raw json
{
"resourceType" : "Bundle",
"id" : "rtpbc-bundle-request-03",
"type" : "collection",
"timestamp" : "2019-11-15T13:10:13-05:00",
"entry" : [
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a",
"resource" : {
"resourceType" : "Claim",
"id" : "rtpbc-claim-03",
"meta" : {
"versionId" : "4",
"lastUpdated" : "2019-11-01T15:51:52.000-04:00"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-claim-03</p><p><b>meta</b>: </p><p><b>identifier</b>: rtpbc-03</p><p><b>status</b>: active</p><p><b>type</b>: Pharmacy <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'pharmacy' = 'Pharmacy', given as 'Pharmacy'})</span></p><p><b>use</b>: predetermination</p><p><b>patient</b>: <a href=\"Patient-rtpbc-patient-03.html\">Generated Summary: id: rtpbc-patient-03; Jane Doe ; gender: female; birthDate: 1975-12-05</a></p><p><b>created</b>: Nov 1, 2019 4:20:54 PM</p><p><b>provider</b>: <a href=\"Organization-rtpbc-organization-03.html\">Generated Summary: id: rtpbc-organization-03; 0999017; <span title=\"Codes: {http://ncpdp.org/pharmacy-type R}\">Retail</span>; name: Hometown Drug; ph: 6081234567</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/processpriority code 'normal' = 'Normal', given as 'Normal'})</span></p><p><b>prescription</b>: <a href=\"MedicationRequest-rtpbc-medicationrequest-03.html\">Generated Summary: id: rtpbc-medicationrequest-03; status: draft; intent: proposal; reported; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/ndc-11 00777310402}\">Prozac 10mg capsule</span></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.html\">Generated Summary: id: rtpbc-practitioner-03; 1234567890; Johnson </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><a href=\"Coverage-rtpbc-coverage-03.html\">Generated Summary: id: rtpbc-coverage-03; status: active</a></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>Prozac 10mg capsule <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ndc11/placeholder code '00777310402' = '00777310402', given as 'Prozac 10mg capsule'})</span></td><td>60 EA</td></tr></table></div>"
},
"identifier" : [
{
"value" : "rtpbc-03"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "pharmacy",
"display" : "Pharmacy"
}
]
},
"use" : "predetermination",
"patient" : {
"reference" : "Patient/rtpbc-patient-03"
},
"created" : "2019-11-01T11:20:54-05:00",
"provider" : {
"reference" : "Organization/rtpbc-organization-03"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal",
"display" : "Normal"
}
]
},
"prescription" : {
"reference" : "MedicationRequest/rtpbc-medicationrequest-03"
},
"careTeam" : [
{
"sequence" : 1,
"provider" : {
"reference" : "Practitioner/rtpbc-practitioner-03"
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/rtpbc-coverage-03"
}
}
],
"item" : [
{
"sequence" : 1,
"careTeamSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://example.org/ndc11/placeholder",
"code" : "00777310402",
"display" : "Prozac 10mg capsule"
}
]
},
"quantity" : {
"value" : 60,
"unit" : "EA"
}
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b",
"resource" : {
"resourceType" : "Patient",
"id" : "rtpbc-patient-03",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-patient-03</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>"
},
"name" : [
{
"family" : "Doe",
"given" : [
"Jane"
]
}
],
"gender" : "female",
"birthDate" : "1975-12-05",
"address" : [
{
"line" : [
"100 Oak Court"
],
"city" : "Madison",
"state" : "WI",
"postalCode" : "53510",
"country" : "US"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0c",
"resource" : {
"resourceType" : "Coverage",
"id" : "rtpbc-coverage-03",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-coverage-03</p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"Patient-rtpbc-patient-03.html\">Generated Summary: id: rtpbc-patient-03; Jane Doe ; gender: female; birthDate: 1975-12-05</a></p><p><b>payor</b>: </p><blockquote><p><b>class</b></p><p><b>type</b>: RX BIN <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/coverage-class code 'rxbin' = 'RX BIN)</span></p><p><b>value</b>: BIN001</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX PCN <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/coverage-class code 'rxpcn' = 'RX PCN)</span></p><p><b>value</b>: PCN002</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX Group <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/coverage-class code 'rxgroup' = 'RX Group)</span></p><p><b>value</b>: GROUP0001</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: RX Id <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/coverage-class code 'rxid' = 'RX Id)</span></p><p><b>value</b>: MEMBER000001</p></blockquote></div>"
},
"status" : "active",
"beneficiary" : {
"reference" : "Patient/rtpbc-patient-03"
},
"payor" : [
{
"identifier" : {
"value" : "Pharmacy Plans US"
}
}
],
"class" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxbin"
}
]
},
"value" : "BIN001"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxpcn"
}
]
},
"value" : "PCN002"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxgroup"
}
]
},
"value" : "GROUP0001"
},
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
"code" : "rxid"
}
]
},
"value" : "MEMBER000001"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0d",
"resource" : {
"resourceType" : "MedicationRequest",
"id" : "rtpbc-medicationrequest-03",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-medicationrequest-03</p><p><b>status</b>: draft</p><p><b>intent</b>: proposal</p><p><b>reported</b>: true</p><p><b>medication</b>: Prozac 10mg capsule <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ndc11/placeholder code '00777310402' = '00777310402', given as 'Prozac 10mg capsule'})</span></p><p><b>subject</b>: <a href=\"Patient-rtpbc-patient-03.html\">Generated Summary: id: rtpbc-patient-03; Jane Doe ; gender: female; birthDate: 1975-12-05</a></p><p><b>requester</b>: <a href=\"Practitioner-rtpbc-practitioner-03.html\">Generated Summary: id: rtpbc-practitioner-03; 1234567890; Johnson </a></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 EA</td><td>30 days<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code d = 'd')</span></td><td><a href=\"Organization-rtpbc-organization-03.html\">Generated Summary: id: rtpbc-organization-03; 0999017; <span title=\"Codes: {http://ncpdp.org/pharmacy-type R}\">Retail</span>; name: Hometown Drug; ph: 6081234567</a></td></tr></table></div>"
},
"status" : "draft",
"intent" : "proposal",
"reportedBoolean" : true,
"medicationCodeableConcept" : {
"coding" : [
{
"system" : "http://example.org/ndc11/placeholder",
"code" : "00777310402",
"display" : "Prozac 10mg capsule"
}
]
},
"subject" : {
"reference" : "Patient/rtpbc-patient-03"
},
"requester" : {
"reference" : "Practitioner/rtpbc-practitioner-03"
},
"dispenseRequest" : {
"quantity" : {
"value" : 60,
"unit" : "EA"
},
"expectedSupplyDuration" : {
"value" : 30,
"unit" : "days",
"system" : "http://unitsofmeasure.org",
"code" : "d"
},
"performer" : {
"reference" : "Organization/rtpbc-organization-03"
}
}
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0e",
"resource" : {
"resourceType" : "Practitioner",
"id" : "rtpbc-practitioner-03",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-practitioner-03</p><p><b>identifier</b>: 1234567890</p><p><b>name</b>: Johnson </p></div>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1234567890"
}
],
"name" : [
{
"family" : "Johnson"
}
]
}
},
{
"fullUrl" : "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0f",
"resource" : {
"resourceType" : "Organization",
"id" : "rtpbc-organization-03",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: rtpbc-organization-03</p><p><b>identifier</b>: 9876543210</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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "9876543210"
}
],
"name" : "Hometown Drug",
"telecom" : [
{
"system" : "phone",
"value" : "6081234567"
}
],
"address" : [
{
"line" : [
"900 9th Street"
],
"city" : "Madison",
"state" : "WI",
"postalCode" : "53535",
"country" : "US"
}
]
}
}
]
}
