Da Vinci - Coverage Requirements Discovery
2.0.1 - STU 2 United States of America flag

This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v2.0.1: STU 2.0) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: MedicationRequest annotated example - XML Representation

Page standards status: Informative

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<MedicationRequest xmlns="http://hl7.org/fhir">
  <id value="annotated-example"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: MedicationRequest</b><a name="annotated-example"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource MedicationRequest &quot;annotated-example&quot; </p></div><blockquote><p><b>Coverage Information</b></p><blockquote><p><b>url</b></p><code>coverage</code></blockquote><p><b>value</b>: <a href="Coverage-example.html">Coverage/example</a></p><blockquote><p><b>url</b></p><code>covered</code></blockquote><p><b>value</b>: conditional</p><blockquote><p><b>url</b></p><code>pa-needed</code></blockquote><p><b>value</b>: satisfied</p><blockquote><p><b>url</b></p><code>doc-needed</code></blockquote><p><b>value</b>: admin</p><blockquote><p><b>url</b></p><code>doc-purpose</code></blockquote><p><b>value</b>: withclaim</p><blockquote><p><b>url</b></p><code>info-needed</code></blockquote><p><b>value</b>: performer</p><blockquote><p><b>url</b></p><code>billingCode</code></blockquote><p><b>value</b>: Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed (Details: http://www.ama-assn.org/go/cpt code 77067 = 'Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed', stated as 'null')</p><blockquote><p><b>url</b></p><code>reason</code></blockquote><p><b>value</b>: In-network required unless exigent circumstances <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-temp.html">CRD Temporary Codes</a>#gold-card)</span></p><p><b>code</b>: Authorization out-of-network only <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-temp.html">CRD Temporary Codes</a>#auth-out-network-only)</span></p><blockquote><p><b>url</b></p><code>detail</code></blockquote><blockquote><p><b>url</b></p><code>questionnaire</code></blockquote><p><b>value</b>: <a href="http://example.org/some-payer/Questionnaire/123">http://example.org/some-payer/Questionnaire/123|1.3.0</a></p><blockquote><p><b>url</b></p><code>response</code></blockquote><p><b>value</b>: <a name="qr"> </a></p><blockquote><p/><p><a name="qr"> </a></p><p><b>questionnaire</b>: <a href="http://example.org/some-payer/Questionnaire/123">http://example.org/some-payer/Questionnaire/123|1.3.0</a></p><p><b>status</b>: in-progress</p><p><b>subject</b>: <a href="http://example.org/Patient/123">http://example.org/Patient/123: Jane Smith</a></p><p><b>authored</b>: 2019-02-15</p><p><b>author</b>: <span>: Some payer app name</span></p><blockquote><p><b>item</b></p><p><b>linkId</b>: A1234</p><p><b>text</b>: How many previous treatments have been tried for this issue?</p><h3>Answers</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>2</td></tr></table></blockquote></blockquote><blockquote><p><b>url</b></p><a href="http://hl7.org/fhir/R4/datatypes.html#date">date</a></blockquote><p><b>value</b>: 2019-02-15</p><blockquote><p><b>url</b></p><code>coverage-assertion-id</code></blockquote><p><b>value</b>: 12345ABC</p><blockquote><p><b>url</b></p><code>satisfied-pa-id</code></blockquote><p><b>value</b>: XXYYZ</p><blockquote><p><b>url</b></p><code>contact</code></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>status</b>: draft</p><p><b>intent</b>: original-order</p><p><b>medication</b>: Cellcept 250 MG Oral Capsule <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-v3-rxNorm.html">RxNorm</a>#616447)</span></p><p><b>subject</b>: <a href="http://example.org/Patient/123">http://example.org/Patient/123: Jane Smith</a></p><p><b>encounter</b>: <a href="http://example.org/Encounter/ABC">http://example.org/Encounter/ABC</a></p><p><b>authoredOn</b>: 2019-02-15</p><p><b>requester</b>: <a href="http://example.org/PractitionerRole/987">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 @Feb 15, 2019, 8:07:18 PM)</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><blockquote><p><b>doseAndRate</b></p></blockquote></blockquote><hr/><blockquote><table border="1" cellpadding="0" cellspacing="0" style="border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;"><tr style="border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top"><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://hl7.org/fhir/R4/formats.html#table" title="The linkId for the item">LinkId</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://hl7.org/fhir/R4/formats.html#table" title="Text for the item">Text</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://hl7.org/fhir/R4/formats.html#table" title="Minimum and Maximum # of times the the itemcan appear in the instance">Definition</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http://hl7.org/fhir/R4/formats.html#table" title="The type of the item">Answer</a><span style="float: right"><a href="http://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_q_root.gif" alt="." style="background-color: white; background-color: inherit" title="QuestionnaireResponseRoot" class="hierarchy"/> qr</td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"></td><td style="vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Questionnaire:http://example.org/some-payer/Questionnaire/123|1.3.0</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="Item" class="hierarchy"/> A1234</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">How many previous treatments have been tried for this issue?</td><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">2</td></tr>
<tr><td colspan="4" class="hierarchy"><br/><a href="http://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></blockquote></div>
  </text>
  <contained>
    <QuestionnaireResponse>
      <id value="qr"/>
      <questionnaire
                     value="http://example.org/some-payer/Questionnaire/123|1.3.0"/>
      <status value="in-progress"/>
      <subject>
        <reference value="http://example.org/Patient/123"/>
        <display value="Jane Smith"/>
      </subject>
      <authored value="2019-02-15"/>
      <author>
        <identifier>
          <system
                  value="http://some-payer.org/xyz-sub-org/identifiers/application-ids"/>
          <value value="payer-CRD-service-id"/>
        </identifier>
        <display value="Some payer app name"/>
      </author>
      <item>
        <linkId value="A1234"/>
        <text
              value="How many previous treatments have been tried for this issue?"/>
        <answer>
          <valueInteger value="2"/>
        </answer>
      </item>
    </QuestionnaireResponse>
  </contained>
  <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="response">
      <valueReference>
        <reference value="#qr"/>
      </valueReference>
    </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>
  <status value="draft"/>
  <intent value="original-order"/>
  <medicationCodeableConcept>
    <coding>
      <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
      <code value="616447"/>
      <display value="Cellcept 250 MG Oral Capsule"/>
    </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>