Reversal Request

{
"resourceType": "Bundle",
"id": "c149ce78-0983-4fc2-ba63-aeac253e933e",
"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-baf4-968d600fbd1e",
"resource": {
"resourceType": "MessageHeader",
"id": "6d8041af-7963-4bff-baf4-968d600fbd1e",
"eventCoding": {
"system": "http://pharmacyeclaims.ca/fhir/CodeSystem/message-events",
"code": "11"
},
"destination": [
{
"name": "Name of Adjudicator",
"endpoint": "urn:oid:2.16.840.1.113883.3.7066.1",
"receiver": {
"reference": "Organization/12345",
"identifier": {
"system": "urn:oid:http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN",
"value": "Device-123"
}
}
}
],
"sender": {
"reference": "Organization/12345",
"identifier": {
"system": "urn:oid:setbyPOSvendor",
"value": "SoftwareVendorClientName"
}
},
"source": {
"name": "thename",
"software": "POS software name",
"version": "POSversion",
"endpoint": "urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc"
},
"responsible": {
"reference": "Organization/086968a8c716",
"identifier": {
"system": "http://pharmacyeclaims.ca/FHIR/PharmacyID",
"value": "Device-123"
}
},
"focus": [
{
"reference": "urn:uuid:6d8041af-7963-4bff-baf4-968d600fbd1"
}
]
}
},
{
"fullUrl": "urn:uuid:6d8041af-7963-4bff-baf4-968d600para",
"resource": {
"resourceType": "Parameters",
"id": "6d8041af-7963-4bff-baf4-968d600fpara",
"parameter": [
{
"name": "AdjudicationDate",
"valueDateTime": "2025-08-01T10:00:00Z"
},
{
"name": "TraceNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR/TraceNumber",
"value": "TRC-9876543210"
}
},
{
"name": "ReferenceNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR/reference",
"value": "REF-1234567890"
}
},
{
"name": "CurrentRXNumber",
"valueIdentifier": {
"system": "http://pharmacyeclaims.ca/FHIR/rx",
"value": "RX-00012345"
}
},
{
"name": "ProviderTransactionDate",
"valueDateTime": "2025-07-31T14:45:00Z"
}
]
}
}
]
}
<!-- edited with XMLSpy - DRAFT Reversal Request August 8 2025 -->
<Bundle xmlns="http://hl7.org/fhir">
<id value="c149ce78-0983-4fc2-ba63-aeac253e933e" />
<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-baf4-968d600fbd1e" />
<!-- first entry must be message header -->
<resource>
<MessageHeader>
<id value="6d8041af-7963-4bff-baf4-968d600fbd1e" />
<eventCoding>
<system value="http://pharmacyeclaims.ca/fhir/CodeSystem/message-events" />
<!-- fixed value -->
<code value="11" />
<!-- used in mapping from A.03.03 - used for both Proff services and Dispense claims -->
</eventCoding>
<destination>
<name value="Name of Adjudicator" />
<!-- Optional; not used unless requested by implementer <target> <reference value="Organization/12345"/> <identifier> <system value="urn:uri:f2c1b9e4-6e88-4e15-99fc-8a48c89d4d73" /> </identifier> </target> -->
<endpoint value="urn:oid:2.16.840.1.113883.3.7066.1" />
<!-- endpoint is mandatory -->
<receiver>
<reference value="Organization/12345" />
<identifier>
<system value="urn:oid:http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN" />
<!-- TBD update profile and this to code system -->
<value value="Device-123" />
<!-- - CPHA Mapping: CPHA Mapping:IN A.01.01( Issuer Identification Number) or a system ID -->
</identifier>
</receiver>
</destination>
<sender>
<!-- Optional, new field only used when requested by adjudicator for troubleshooting purposes -->
<reference value="Organization/12345" />
<identifier>
<system value="urn:oid:setbyPOSvendor" />
<value value="SoftwareVendorClientName" />
</identifier>
</sender>
<source>
<name value="thename" />
<!-- CPHA Mapping: A.07.03 Device ID -->
<!-- optional, new, only use upon request -->
<software value="POS software name" />
<!-- CPHA Mapping: Provider Software ID A.04.03 -->
<version value="POSversion" />
<!-- CPHA Mapping: Provider Software Version A.05.03 -->
<endpoint value="urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc" />
</source>
<responsible>
<!-- optional, upon request -->
<reference value="Organization/086968a8c716" />
<identifier>
<system value="http://pharmacyeclaims.ca/FHIR/PharmacyID" />
<!-- identifier mandatory for reversal request -->
<value value="Device-123" />
<!-- - CPHA Mapping: -->
</identifier>
<!-- reference to pharmacy org resource -->
</responsible>
<focus>
<reference value="urn:uuid:6d8041af-7963-4bff-baf4-968d600fbd1" />
<!-- mandatory reference to the claim -->
</focus>
</MessageHeader>
</resource>
</entry>
<entry>
<fullUrl value="urn:uuid:6d8041af-7963-4bff-baf4-968d600para" />
<resource>
<Parameters>
<id value="6d8041af-7963-4bff-baf4-968d600fpara" />
<parameter>
<name value="AdjudicationDate" />
<!-- Adjudication Date (ClaimResponse.created) -->
<valueDateTime value="2025-08-01T10:00:00Z" />
</parameter>
<!-- Trace Number -->
<parameter>
<name value="TraceNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR/TraceNumber" />
<value value="TRC-9876543210" />
</valueIdentifier>
</parameter>
<!-- Reference Number (optional but present here) -->
<parameter>
<name value="ReferenceNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR/reference" />
<value value="REF-1234567890" />
</valueIdentifier>
</parameter>
<!-- Current RX Number -->
<parameter>
<name value="CurrentRXNumber" />
<valueIdentifier>
<system value="http://pharmacyeclaims.ca/FHIR/rx" />
<value value="RX-00012345" />
</valueIdentifier>
</parameter>
<!-- Provider Transaction Date (Claim.created) -->
<parameter>
<name value="ProviderTransactionDate" />
<valueDateTime value="2025-07-31T14:45:00Z" />
</parameter>
</Parameters>
</resource>
</entry>
</Bundle>
Bundle.id[0]c149ce78-0983-4fc2-ba63-aeac253e933e
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-baf4-968d600fbd1e
Bundle.entry[0].resource[0].id[0]6d8041af-7963-4bff-baf4-968d600fbd1e
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]11
Bundle.entry[0].resource[0].destination[0].name[0]Name of Adjudicator
Bundle.entry[0].resource[0].destination[0].endpoint[0]urn:oid:2.16.840.1.113883.3.7066.1
Bundle.entry[0].resource[0].destination[0].receiver[0].reference[0]Organization/12345
Bundle.entry[0].resource[0].destination[0].receiver[0].identifier[0].system[0]urn:oid:http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN
Bundle.entry[0].resource[0].destination[0].receiver[0].identifier[0].value[0]Device-123
Bundle.entry[0].resource[0].sender[0].reference[0]Organization/12345
Bundle.entry[0].resource[0].sender[0].identifier[0].system[0]urn:oid:setbyPOSvendor
Bundle.entry[0].resource[0].sender[0].identifier[0].value[0]SoftwareVendorClientName
Bundle.entry[0].resource[0].source[0].name[0]thename
Bundle.entry[0].resource[0].source[0].software[0]POS software name
Bundle.entry[0].resource[0].source[0].version[0]POSversion
Bundle.entry[0].resource[0].source[0].endpoint[0]urn:uuid:2fcd0a14-4ad6-11e8-9c2d-fa7ae01bbebc
Bundle.entry[0].resource[0].responsible[0].reference[0]Organization/086968a8c716
Bundle.entry[0].resource[0].responsible[0].identifier[0].system[0]http://pharmacyeclaims.ca/FHIR/PharmacyID
Bundle.entry[0].resource[0].responsible[0].identifier[0].value[0]Device-123
Bundle.entry[0].resource[0].focus[0].reference[0]urn:uuid:6d8041af-7963-4bff-baf4-968d600fbd1
Bundle.entry[1].fullUrl[0]urn:uuid:6d8041af-7963-4bff-baf4-968d600para
Bundle.entry[1].resource[0].id[0]6d8041af-7963-4bff-baf4-968d600fpara
Bundle.entry[1].resource[0].parameter[0].name[0]AdjudicationDate
Bundle.entry[1].resource[0].parameter[0].value[0]2025-08-01T10:00:00Z
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/TraceNumber
Bundle.entry[1].resource[0].parameter[1].value[0].value[0]TRC-9876543210
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
Bundle.entry[1].resource[0].parameter[2].value[0].value[0]REF-1234567890
Bundle.entry[1].resource[0].parameter[3].name[0]CurrentRXNumber
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]RX-00012345
Bundle.entry[1].resource[0].parameter[4].name[0]ProviderTransactionDate
Bundle.entry[1].resource[0].parameter[4].value[0]2025-07-31T14:45:00Z