{
"resourceType": "Bundle",
"id": "rtpbc-bundle-request-03-w-header",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-bundle"
]
},
"type": "message",
"timestamp": "2019-11-15T13:10:13-05:00",
"entry": [
{
"fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0a",
"resource": {
"resourceType": "MessageHeader",
"id": "rtpbc-messageheader-request-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-messageheader"
]
},
"text": {
"status": "generated",
"div": "<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>"
},
"eventCoding": {
"system": "http://hl7.org/fhir/us/carin-rtpbc/CodeSystem/rtpbc-event-type",
"code": "rtpbc-request",
"display": "RTPBC Request"
},
"source": {
"name": "MyPatientApp",
"endpoint": "http://example.org/MyPatientApp"
},
"focus": [
{
"reference": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b"
}
],
"definition": "http://hl7.org/fhir/us/carin-rtpbc/MessageDefinition/rtpbc-request"
}
},
{
"fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0b",
"resource": {
"resourceType": "Claim",
"id": "rtpbc-claim-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim"
]
},
"text": {
"status": "generated",
"div": "<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><a href=\"#Coverage_rtpbc-coverage-03\">See above (Coverage/rtpbc-coverage-03)</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><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>"
},
"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://www.nlm.nih.gov/research/umls/rxnorm",
"code": "205535",
"display": "PROzac 10 MG Oral Capsule"
}
]
},
"quantity": {
"value": 60,
"unit": "{Each}"
}
}
]
}
},
{
"fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0c",
"resource": {
"resourceType": "Patient",
"id": "rtpbc-patient-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient"
]
},
"text": {
"status": "generated",
"div": "<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>"
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "PI",
"display": "Patient internal identifier"
}
],
"text": "Patient internal identifier"
},
"system": "http://example.org/MyPatientApp",
"value": "30455"
}
],
"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-c5e300945f0d",
"resource": {
"resourceType": "Coverage",
"id": "rtpbc-coverage-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage"
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>id</b>: rtpbc-coverage-03</p><p><b>meta</b>: </p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"#Patient_rtpbc-patient-03\">See above (Patient/rtpbc-patient-03)</a></p><p><b>payor</b>: <span></span></p><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxbin}\">RX BIN</span></p><p><b>value</b>: BIN001</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxpcn}\">RX PCN</span></p><p><b>value</b>: PCN002</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/coverage-class rxgroup}\">RX Group</span></p><p><b>value</b>: GROUP0001</p></blockquote><blockquote><p><b>class</b></p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/coverage-class 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-c5e300945f0e",
"resource": {
"resourceType": "MedicationRequest",
"id": "rtpbc-medicationrequest-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest"
]
},
"text": {
"status": "generated",
"div": "<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>"
},
"status": "draft",
"intent": "proposal",
"reportedBoolean": true,
"medicationCodeableConcept": {
"coding": [
{
"system": "http://www.nlm.nih.gov/research/umls/rxnorm",
"code": "205535",
"display": "PROzac 10 MG Oral Capsule"
}
]
},
"subject": {
"reference": "Patient/rtpbc-patient-03"
},
"authoredOn": "2019-11-01",
"requester": {
"reference": "Practitioner/rtpbc-practitioner-03"
},
"dosageInstruction": [
{
"text": "Take 2 capsules once a day"
}
],
"dispenseRequest": {
"quantity": {
"value": 60,
"unit": "{Each}"
},
"expectedSupplyDuration": {
"value": 30,
"unit": "days",
"system": "http://unitsofmeasure.org",
"code": "d"
},
"performer": {
"reference": "Organization/rtpbc-organization-03"
}
},
"substitution": {
"allowedBoolean": false
}
}
},
{
"fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0f",
"resource": {
"resourceType": "Practitioner",
"id": "rtpbc-practitioner-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"
]
},
"text": {
"status": "generated",
"div": "<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>"
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1234567890"
}
],
"name": [
{
"family": "Johnson"
}
]
}
},
{
"fullUrl": "urn:uuid:61ebe359-bfdc-4613-8bf2-c5e300945f0g",
"resource": {
"resourceType": "Organization",
"id": "rtpbc-organization-03",
"meta": {
"profile": [
"http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization"
]
},
"text": {
"status": "generated",
"div": "<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>"
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "9876543210"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://ncpdp.org/pharmacy-type",
"code": "R",
"display": "Retail"
}
]
}
],
"name": "Hometown Drug",
"telecom": [
{
"system": "phone",
"value": "6081234567"
}
],
"address": [
{
"line": [
"900 9th Street"
],
"city": "Madison",
"state": "WI",
"postalCode": "53535",
"country": "US"
}
]
}
}
]
}