Da Vinci - Coverage Requirements Discovery
1.0.0 - STU 1

This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ClaimResponse: Prior Authorization example

Generated Narrative

status: active

type: Oral

use: preauthorization

patient: Generated Summary: Medical Record Number: 1032702 (USUAL); active; Amy V. Shaw , Amy V. Baxter ; Phone: 555-555-5555, amy.shaw@example.com; gender: female; birthDate: 1987-02-20

created: 2014-08-16

insurer:

outcome: complete

disposition: The enclosed services are authorized for your provision within 30 days of this notice.

preAuthRef: 18SS12345

payeeType: Provider

addItem

itemSequence: 1

productOrService: 1101

modifier: None

Nets

-
*

noteNumber: 101

adjudication

category: Eligible Amount

Amounts

-
*

adjudication

category: CoPay

Amounts

-
*

adjudication

category: Eligible %

value: 100.00

adjudication

category: Benefit Amount

Amounts

-
*

addItem

itemSequence: 1

productOrService: Radiograph, series (12)

Nets

-
*

adjudication

category: Eligible Amount

Amounts

-
*

adjudication

category: Eligible %

value: 100.00

adjudication

category: Benefit Amount

Amounts

-
*

total

category: Submitted Amount

Amounts

-
*

total

category: Benefit Amount

Amounts

-
*

ProcessNotes

-NumberTypeTextLanguage
*101printPlease submit a Pre-Authorization request if a more extensive examination or urgent services are required.English (Region=Canada)

Insurances

-SequenceFocalCoverage
*1trueGenerated Summary: id: 12345; status: active; extended healthcare; dependent: 0; Self; period: 2011-05-23 --> 2012-05-23