Da Vinci Health Record Exchange (HRex)
1.1.0-ballot - STU 1.1 Ballot United States of America flag

This page is part of the Da Vinci Health Record Exchange (v1.1.0-ballot: STU 1.1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

: Unsolicited Prior Authorization example - XML Representation

Page standards status: Informative

Raw xml | Download



<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="UnsolicitedReferralAuthorizationResponseExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-claimresponse"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse UnsolicitedReferralAuthorizationResponseExample</b></p><a name="UnsolicitedReferralAuthorizationResponseExample"> </a><a name="hcUnsolicitedReferralAuthorizationResponseExample"> </a><a name="UnsolicitedReferralAuthorizationResponseExample-en-US"> </a><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&amp;canonical=http://example.org/new-payer/fhir/Patient/pat1">??</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href="Organization-full.html">Organization New Health Plan</a></p><p><b>requestor</b>: <a href="https://simplifier.net/resolve?scope=hl7.fhir.us.core.3.1.1@3.1.1&amp;canonical=http://example.org/someProvider/fhir/Organization/good-health-clinic">??</a></p><p><b>outcome</b>: Processing Complete</p><p><b>preAuthRef</b>: A1B2C3D4</p><blockquote><p><b>addItem</b></p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></p><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></blockquote></div>
  </text>
  <identifier>
    <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
    <value value="111099"/>
    <assigner>
      <identifier>
        <system value="http://example.org/USER_ASSIGNED"/>
        <value value="9012345678"/>
      </identifier>
    </assigner>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>
    <reference value="http://example.org/new-payer/fhir/Patient/pat1"/>
  </patient>
  <created value="2005-05-02T11:02:00+05:00"/>
  <insurer>🔗 
    <reference value="Organization/full"/>
  </insurer>
  <requestor>
    <reference
               value="http://example.org/someProvider/fhir/Organization/good-health-clinic"/>
  </requestor>
  <outcome value="complete"/>
  <preAuthRef value="A1B2C3D4"/>
  <addItem>
    <extension
               url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemAuthorizedDate">
      <valuePeriod>
        <start value="2005-05-02"/>
        <end value="2005-06-02"/>
      </valuePeriod>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemPreAuthIssueDate">
      <valueDate value="2005-05-02"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemAuthorizedProvider">
      <valueReference>🔗 
        <reference value="Practitioner/full"/>
      </valueReference>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-itemTraceNumber">
      <valueIdentifier>
        <system
                value="http://example.org/new-payer/fhir/NamingSystem/auth-numbers"/>
        <value value="A1B2C3D4"/>
      </valueIdentifier>
    </extension>
    <itemSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://codesystem.x12.org/005010/1365"/>
        <code value="3"/>
        <display value="Consultation"/>
      </coding>
    </productOrService>
    <locationCodeableConcept>
      <coding>
        <system
                value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
        <code value="11"/>
      </coding>
    </locationCodeableConcept>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
    </adjudication>
  </addItem>
</ClaimResponse>