Reversal Accepted Response

{
"resourceType": "Bundle",
"id": "6d8041af-7963-4bff-baf4-968d600gbd1e",
"meta": {
"tag": [
{
"system": "http://pharmacyeclaims.ca/FHIR/CodeSystem/message-version",
"code": "1.0"
}
]
},
"type": "message",
"timestamp": "2025-01-06T22:03:23Z",
"entry": [
{
"fullUrl": "urn:uuid:6d8041af-7963-4bff-baf4-968d600gbd1e",
"resource": {
"resourceType": "MessageHeader",
"id": "6d8041af-7963-4bff-baf4-968d600fbond",
"eventCoding": {
"system": "http://pharmacyeclaims.ca/fhir/CodeSystem/message-events",
"code": "61"
},
"destination": [
{
"name": "Name of Sending System",
"target": {
"reference": "Organization/b5c8a272-b078-4ac7-b53d-086968a8c716"
},
"endpoint": "urn:oid:2.16.840.1.113883.3.7066.2"
}
],
"source": {
"endpoint": "urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc"
},
"response": {
"identifier": "6d8041af-7963-4bff-baf4-968d600fbd1e",
"code": "ok"
},
"focus": [
{
"reference": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs"
}
]
}
},
{
"fullUrl": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs",
"resource": {
"resourceType": "Parameters",
"id": "6d8041af-7963-4bff-baf4-968d600revr",
"parameter": [
{
"name": "AdjudicationDate",
"valueDateTime": "2025-08-01T12:00:00Z"
},
{
"name": "TraceNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR/trace-number",
"value": "TRACE123456"
}
},
{
"name": "ReferenceNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR/reference-number",
"value": "REF987654"
}
},
{
"name": "ClaimOrCurrentRXNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR//rx",
"value": "RX20230808001"
}
},
{
"name": "ResponseStatus",
"valueCode": "V"
},
{
"name": "ReversalAmount",
"valueMoney": {
"value": 123.45
}
},
{
"name": "PayeeType",
"valueString": "Provider"
}
]
}
}
]
}
<!-- edited with XMLSpy - DRAFT Reversal Response, Successful Status=V August 8 2025 -->
<Bundle xmlns="http://hl7.org/fhir">
<id value="6d8041af-7963-4bff-baf4-968d600gbd1e" />
<meta>
<tag>
<system value="http://pharmacyeclaims.ca/FHIR/CodeSystem/message-version" />
<!-- fixed value -->
<code value="1.0" />
</tag>
</meta>
<type value="message" />
<timestamp value="2025-01-06T22:03:23Z" />
<!-- mandatory -->
<entry>
<fullUrl value="urn:uuid:6d8041af-7963-4bff-baf4-968d600gbd1e" />
<!-- first entry must be message header -->
<resource>
<MessageHeader>
<id value="6d8041af-7963-4bff-baf4-968d600fbond" />
<eventCoding>
<system value="http://pharmacyeclaims.ca/fhir/CodeSystem/message-events" />
<!-- fixed value -->
<code value="61" />
<!-- used in mapping from A.03.03; new values for FHIR - -->
</eventCoding>
<destination>
<name value="Name of Sending System" />
<!-- New; only used if requested by network -->
<target>
<reference value="Organization/b5c8a272-b078-4ac7-b53d-086968a8c716" />
</target>
<endpoint value="urn:oid:2.16.840.1.113883.3.7066.2" />
<!-- network -->
<!-- mandatory -->
</destination>
<source>
<endpoint value="urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc" />
<!-- - CPHA Mapping: IIN A.01.01( Issuer Identification Number) -->
</source>
<response>
<identifier value="6d8041af-7963-4bff-baf4-968d600fbd1e" />
<!-- MessageHeader.id from the request -->
<code value="ok" />
<!-- New; values are ok | transient-error | fatal-error -->
</response>
<focus>
<reference value="urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs" />
<!-- mandatory reference to the claim -->
</focus>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs" />
<resource>
<Parameters>
<id value="6d8041af-7963-4bff-baf4-968d600revr" />
<!-- Adjudication Date CPHA Map: D.77.03 Adjudication Date -->
<parameter>
<name value="AdjudicationDate" />
<valueDateTime value="2025-08-01T12:00:00Z" />
</parameter>
<!-- Trace Number CPHA map: E.02.03 Trace Number. -->
<parameter>
<name value="TraceNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR/trace-number" />
<value value="TRACE123456" />
</valueIdentifier>
</parameter>
<!-- Reference Number (Optional) CPHA map: E.04. 03 Reference Number -->
<parameter>
<name value="ReferenceNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR/reference-number" />
<value value="REF987654" />
</valueIdentifier>
</parameter>
<!-- Claim or Current RX Number CPHA Map: D.55.03 -->
<parameter>
<name value="ClaimOrCurrentRXNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR//rx" />
<value value="RX20230808001" />
</valueIdentifier>
</parameter>
<!-- Response Status CPHA Map: E.05.03 Response Status -->
<parameter>
<name value="ResponseStatus" />
<valueCode value="V" />
</parameter>
<!-- Response Codes (only present if ResponseStatus = R) -->
<!-- Example below would mot be present since this is accepted ResponseStatus is "V" <parameter> <name value="ResponseCodes"/> <valueCode value="A8"/> </parameter> -->
<!-- Reversal Amount -->
<parameter>
<name value="ReversalAmount" />
<valueMoney>
<value value="123.45" />
</valueMoney>
</parameter>
<!-- Payee Type -->
<parameter>
<name value="PayeeType" />
<valueString value="Provider" />
</parameter>
</Parameters>
</resource>
</entry>
</Bundle>
Bundle.id[0]6d8041af-7963-4bff-baf4-968d600gbd1e
Bundle.meta[0].tag[0].system[0]http://pharmacyeclaims.ca/FHIR/CodeSystem/message-version
Bundle.meta[0].tag[0].code[0]1.0
Bundle.type[0]message
Bundle.timestamp[0]2025-01-06T22:03:23+00:00
Bundle.entry[0].fullUrl[0]urn:uuid:6d8041af-7963-4bff-baf4-968d600gbd1e
Bundle.entry[0].resource[0].id[0]6d8041af-7963-4bff-baf4-968d600fbond
Bundle.entry[0].resource[0].event[0].system[0]http://pharmacyeclaims.ca/fhir/CodeSystem/message-events
Bundle.entry[0].resource[0].event[0].code[0]61
Bundle.entry[0].resource[0].destination[0].name[0]Name of Sending System
Bundle.entry[0].resource[0].destination[0].target[0].reference[0]Organization/b5c8a272-b078-4ac7-b53d-086968a8c716
Bundle.entry[0].resource[0].destination[0].endpoint[0]urn:oid:2.16.840.1.113883.3.7066.2
Bundle.entry[0].resource[0].source[0].endpoint[0]urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc
Bundle.entry[0].resource[0].response[0].identifier[0]6d8041af-7963-4bff-baf4-968d600fbd1e
Bundle.entry[0].resource[0].response[0].code[0]ok
Bundle.entry[0].resource[0].focus[0].reference[0]urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs
Bundle.entry[1].fullUrl[0]urn:uuid:6d8041af-7963-4bff-baf4-968d600fclrs
Bundle.entry[1].resource[0].id[0]6d8041af-7963-4bff-baf4-968d600revr
Bundle.entry[1].resource[0].parameter[0].name[0]AdjudicationDate
Bundle.entry[1].resource[0].parameter[0].value[0]2025-08-01T12:00:00Z
Bundle.entry[1].resource[0].parameter[1].name[0]TraceNumber
Bundle.entry[1].resource[0].parameter[1].value[0].system[0]http://pharmacyeclaims.ca/FHIR/trace-number
Bundle.entry[1].resource[0].parameter[1].value[0].value[0]TRACE123456
Bundle.entry[1].resource[0].parameter[2].name[0]ReferenceNumber
Bundle.entry[1].resource[0].parameter[2].value[0].system[0]http://pharmacyeclaims.ca/FHIR/reference-number
Bundle.entry[1].resource[0].parameter[2].value[0].value[0]REF987654
Bundle.entry[1].resource[0].parameter[3].name[0]ClaimOrCurrentRXNumber
Bundle.entry[1].resource[0].parameter[3].value[0].system[0]http://pharmacyeclaims.ca/FHIR//rx
Bundle.entry[1].resource[0].parameter[3].value[0].value[0]RX20230808001
Bundle.entry[1].resource[0].parameter[4].name[0]ResponseStatus
Bundle.entry[1].resource[0].parameter[4].value[0]V
Bundle.entry[1].resource[0].parameter[5].name[0]ReversalAmount
Bundle.entry[1].resource[0].parameter[5].value[0].value[0]123.45
Bundle.entry[1].resource[0].parameter[6].name[0]PayeeType
Bundle.entry[1].resource[0].parameter[6].value[0]Provider