Da Vinci - Coverage Requirements Discovery
2.1.0 - STU 2.1
Da Vinci - Coverage Requirements Discovery
2.1.0 - STU 2.1
This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v2.1.0: STU 2.1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
<MedicationRequest xmlns="http://hl7.org/fhir">
<id value="annotated-example"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: MedicationRequest annotated-example</b></p><a name="annotated-example"> </a><a name="hcannotated-example"> </a><a name="annotated-example-en-US"> </a><blockquote><p><b>Coverage Information</b></p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/coverage">coverage</a></blockquote><p><b>value</b>: <a href="Coverage-example.html">Coverage: identifier = Member Number; status = active; type = extended healthcare; dependent = 0; relationship = Self; period = 2011-05-23 --> 2012-05-23</a></p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/covered">covered</a></blockquote><p><b>value</b>: conditional</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/pa-needed">pa-needed</a></blockquote><p><b>value</b>: satisfied</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/doc-needed">doc-needed</a></blockquote><p><b>value</b>: admin</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/doc-purpose">doc-purpose</a></blockquote><p><b>value</b>: withclaim</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/info-needed">info-needed</a></blockquote><p><b>value</b>: performer</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/billingCode">billingCode</a></blockquote><p><b>value</b>: <a href="http://terminology.hl7.org/5.0.0/CodeSystem-CPT.html#CPT-77067">Current Procedural Terminology (CPT®) 77067</a>: Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/reason">reason</a></blockquote><p><b>value</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp gold-card}">In-network required unless exigent circumstances</span></p><p><b>code</b>: <span title="Codes:{http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp auth-out-network-only}">Authorization out-of-network only</span></p><p><b>value</b>: true</p><p><b>qualification</b>: Out-of-network prior auth does not apply if delivery occurs at a service site designated as 'remote'</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/detail">detail</a></blockquote><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/questionnaire">questionnaire</a></blockquote><p><b>value</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/some-payer/Questionnaire/123|1.3.0">http://example.org/some-payer/Questionnaire/123|1.3.0</a></p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/date">date</a></blockquote><p><b>value</b>: 2019-02-15</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/coverage-assertion-id">coverage-assertion-id</a></blockquote><p><b>value</b>: 12345ABC</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/satisfied-pa-id">satisfied-pa-id</a></blockquote><p><b>value</b>: XXYYZ</p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/contact">contact</a></blockquote><p><b>value</b>: <a href="http://some-payer.org/xyz-sub-org/get-help-here.html">http://some-payer.org/xyz-sub-org/get-help-here.html</a></p><blockquote><p><b>url</b></p><a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://hl7.org/fhir/us/core/expiry-date">expiry-date</a></blockquote><p><b>value</b>: 2019-08-01</p></blockquote><p><b>status</b>: Draft</p><p><b>intent</b>: Original Order</p><p><b>medication</b>: <span title="Codes:{http://www.nlm.nih.gov/research/umls/rxnorm 616447}">mycophenolate mofetil 250 MG Oral Capsule [Cellcept]</span></p><p><b>subject</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/Patient/123">Jane Smith</a></p><p><b>encounter</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/Encounter/ABC">??</a></p><p><b>authoredOn</b>: 2019-02-15</p><p><b>requester</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.v610@6.1.0&canonical=http://example.org/PractitionerRole/987">Dr. Jones</a></p><p><b>note</b>: Unsolicited prior authorization for Jane Smith to receive 6 tablets Cellcept 250 MG Oral Capsule BID granted. Please note prior authorization # 12345 on claim submission. (By XYZ Insurance @2019-02-15 15:07:18-0500)</p><blockquote><p><b>dosageInstruction</b></p><p><b>text</b>: 6 tablets every 12 hours.</p><p><b>timing</b>: Once per 12 hours</p><h3>DoseAndRates</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Dose[x]</b></td></tr><tr><td style="display: none">*</td><td>6 tablet</td></tr></table></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information">
<extension url="coverage">
<valueReference>🔗
<reference value="Coverage/example"/>
</valueReference>
</extension>
<extension url="covered">
<valueCode value="conditional"/>
</extension>
<extension url="pa-needed">
<valueCode value="satisfied"/>
</extension>
<extension url="doc-needed">
<valueCode value="admin"/>
</extension>
<extension url="doc-purpose">
<valueCode value="withclaim"/>
</extension>
<extension url="info-needed">
<valueCode value="performer"/>
</extension>
<extension url="billingCode">
<valueCoding>
<system value="http://www.ama-assn.org/go/cpt"/>
<code value="77067"/>
</valueCoding>
</extension>
<extension url="reason">
<valueCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"/>
<code value="gold-card"/>
</coding>
<text value="In-network required unless exigent circumstances"/>
</valueCodeableConcept>
</extension>
<extension url="detail">
<extension url="code">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"/>
<code value="auth-out-network-only"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="value">
<valueBoolean value="true"/>
</extension>
<extension url="qualification">
<valueString
value="Out-of-network prior auth does not apply if delivery occurs at a service site designated as 'remote'"/>
</extension>
</extension>
<extension url="questionnaire">
<valueCanonical
value="http://example.org/some-payer/Questionnaire/123|1.3.0"/>
</extension>
<extension url="date">
<valueDate value="2019-02-15"/>
</extension>
<extension url="coverage-assertion-id">
<valueString value="12345ABC"/>
</extension>
<extension url="satisfied-pa-id">
<valueString value="XXYYZ"/>
</extension>
<extension url="contact">
<valueContactPoint>
<system value="url"/>
<value value="http://some-payer.org/xyz-sub-org/get-help-here.html"/>
</valueContactPoint>
</extension>
<extension url="expiry-date">
<valueDate value="2019-08-01"/>
</extension>
</extension>
<status value="draft"/>
<intent value="original-order"/>
<medicationCodeableConcept>
<coding>
<system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
<code value="616447"/>
<display value="mycophenolate mofetil 250 MG Oral Capsule [Cellcept]"/>
</coding>
</medicationCodeableConcept>
<subject>
<reference value="http://example.org/Patient/123"/>
<display value="Jane Smith"/>
</subject>
<encounter>
<reference value="http://example.org/Encounter/ABC"/>
</encounter>
<authoredOn value="2019-02-15"/>
<requester>
<reference value="http://example.org/PractitionerRole/987"/>
<display value="Dr. Jones"/>
</requester>
<note>
<authorString value="XYZ Insurance"/>
<time value="2019-02-15T15:07:18-05:00"/>
<text
value="Unsolicited prior authorization for Jane Smith to receive 6 tablets Cellcept 250 MG Oral Capsule BID granted. Please note prior authorization # 12345 on claim submission."/>
</note>
<dosageInstruction>
<text value="6 tablets every 12 hours."/>
<timing>
<repeat>
<frequency value="1"/>
<period value="12"/>
<periodUnit value="h"/>
</repeat>
</timing>
<doseAndRate>
<doseQuantity>
<value value="6"/>
<unit value="tablet"/>
</doseQuantity>
</doseAndRate>
</dosageInstruction>
</MedicationRequest>
IG © 2019+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-crd#2.1.0 based on FHIR 4.0.1. Generated 2024-12-11
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