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 
XML Format: Bundle-rtpbc-bundle-request-03
Raw xml
<Bundle xmlns="http://hl7.org/fhir"> <id value="rtpbc-bundle-request-03"/> <type value="collection"/> <timestamp value="2019-11-15T13:10:13-05:00"/> <entry> <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a"/> <resource> <Claim> <id value="rtpbc-claim-03"/> <meta> <versionId value="4"/> <lastUpdated value="2019-11-01T15:51:52.000-04:00"/> </meta> <text> <status value="generated"/> <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> </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> <reference value="Coverage/rtpbc-coverage-03"/> </coverage> </insurance> <item> <sequence value="1"/> <careTeamSequence value="1"/> <productOrService> <coding> <system value="http://example.org/ndc11/placeholder"/> <code value="00777310402"/> <display value="Prozac 10mg capsule"/> </coding> </productOrService> <quantity> <value value="60"/> <unit value="EA"/> </quantity> </item> </Claim> </resource> </entry> <entry> <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b"/> <resource> <Patient> <id value="rtpbc-patient-03"/> <text> <status value="generated"/> <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> </text> <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-c5e300945f0c"/> <resource> <Coverage> <id value="rtpbc-coverage-03"/> <text> <status value="generated"/> <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> </text> <status value="active"/> <beneficiary> <reference value="Patient/rtpbc-patient-03"/> </beneficiary> <payor> <identifier> <value value="Pharmacy Plans US"/> </identifier> </payor> <class> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> <code value="rxbin"/> </coding> </type> <value value="BIN001"/> </class> <class> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> <code value="rxpcn"/> </coding> </type> <value value="PCN002"/> </class> <class> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> <code value="rxgroup"/> </coding> </type> <value value="GROUP0001"/> </class> <class> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/> <code value="rxid"/> </coding> </type> <value value="MEMBER000001"/> </class> </Coverage> </resource> </entry> <entry> <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0d"/> <resource> <MedicationRequest> <id value="rtpbc-medicationrequest-03"/> <text> <status value="generated"/> <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> </text> <status value="draft"/> <intent value="proposal"/> <reportedBoolean value="true"/> <medicationCodeableConcept> <coding> <system value="http://example.org/ndc11/placeholder"/> <code value="00777310402"/> <display value="Prozac 10mg capsule"/> </coding> </medicationCodeableConcept> <subject> <reference value="Patient/rtpbc-patient-03"/> </subject> <requester> <reference value="Practitioner/rtpbc-practitioner-03"/> </requester> <dispenseRequest> <quantity> <value value="60"/> <unit value="EA"/> </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> </MedicationRequest> </resource> </entry> <entry> <fullUrl value="urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0e"/> <resource> <Practitioner> <id value="rtpbc-practitioner-03"/> <text> <status value="generated"/> <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> </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-c5e300945f0f"/> <resource> <Organization> <id value="rtpbc-organization-03"/> <text> <status value="generated"/> <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> </text> <identifier> <system value="http://hl7.org/fhir/sid/us-npi"/> <value value="9876543210"/> </identifier> <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>
