Da Vinci - Coverage Requirements Discovery
1.0.0 - STU 1
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 
{
"resourceType" : "ClaimResponse",
"id" : "priorauth-example",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>type</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/claim-type oral}\">Oral</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient-example.html\">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</a></p><p><b>created</b>: 2014-08-16</p><p><b>insurer</b>: <span></span></p><p><b>outcome</b>: complete</p><p><b>disposition</b>: The enclosed services are authorized for your provision within 30 days of this notice.</p><p><b>preAuthRef</b>: 18SS12345</p><p><b>payeeType</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/payeetype provider}\">Provider</span></p><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes: {http://example.org/fhir/oralservicecodes 1101}\">1101</span></p><p><b>modifier</b>: <span title=\"Codes: {http://example.org/fhir/modifiers x}\">None</span></p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>noteNumber</b>: 101</p><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication copay}\">CoPay</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>value</b>: 100.00</p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes: {http://example.org/fhir/oralservicecodes 2101}\">Radiograph, series (12)</span></p><h3>Nets</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligible}\">Eligible Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication eligpercent}\">Eligible %</span></p><p><b>value</b>: 100.00</p></blockquote><blockquote><p><b>adjudication</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/adjudication benefit}\">Benefit Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote><h3>ProcessNotes</h3><table class=\"grid\"><tr><td>-</td><td><b>Number</b></td><td><b>Type</b></td><td><b>Text</b></td><td><b>Language</b></td></tr><tr><td>*</td><td>101</td><td>print</td><td>Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.</td><td><span title=\"Codes: {urn:ietf:bcp:47 en-CA}\">English (Region=Canada)</span></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-example.html\">Generated Summary: id: 12345; status: active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ActCode EHCPOL}\">extended healthcare</span>; dependent: 0; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/subscriber-relationship self}\">Self</span>; period: 2011-05-23 --> 2012-05-23</a></td></tr></table></div>"
},
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "oral"
}
]
},
"use" : "preauthorization",
"patient" : {
"reference" : "Patient/example"
},
"created" : "2014-08-16",
"insurer" : {
"identifier" : {
"system" : "http://www.jurisdiction.org/insurers",
"value" : "444123"
}
},
"outcome" : "complete",
"disposition" : "The enclosed services are authorized for your provision within 30 days of this notice.",
"preAuthRef" : "18SS12345",
"payeeType" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/payeetype",
"code" : "provider"
}
]
},
"addItem" : [
{
"itemSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "1101"
}
]
},
"modifier" : [
{
"coding" : [
{
"system" : "http://example.org/fhir/modifiers",
"code" : "x",
"display" : "None"
}
]
}
],
"net" : {
"value" : 250.00,
"currency" : "USD"
},
"noteNumber" : [
101
],
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 250.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "copay"
}
]
},
"amount" : {
"value" : 10.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent"
}
]
},
"value" : 100.00
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 240.00,
"currency" : "USD"
}
}
]
},
{
"itemSequence" : [
1
],
"productOrService" : {
"coding" : [
{
"system" : "http://example.org/fhir/oralservicecodes",
"code" : "2101",
"display" : "Radiograph, series (12)"
}
]
},
"net" : {
"value" : 800.00,
"currency" : "USD"
},
"adjudication" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligible"
}
]
},
"amount" : {
"value" : 800.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "eligpercent"
}
]
},
"value" : 100.00
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 800.00,
"currency" : "USD"
}
}
]
}
],
"total" : [
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
},
"amount" : {
"value" : 1050.00,
"currency" : "USD"
}
},
{
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "benefit"
}
]
},
"amount" : {
"value" : 1040.00,
"currency" : "USD"
}
}
],
"processNote" : [
{
"number" : 101,
"type" : "print",
"text" : "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.",
"language" : {
"coding" : [
{
"system" : "urn:ietf:bcp:47",
"code" : "en-CA"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/example"
}
}
]
}
IG © 2019+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-crd#1.0.0 based on FHIR 4.0.1. Generated 2020-12-22
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