Da Vinci Health Record Exchange (HRex)
1.0.0 - STU R1 US

This page is part of the Da Vinci Health Record Exchange (v1.0.0: STU1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Unsolicited Prior Authorization example - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="UnsolicitedReferralAuthorizationResponseExample"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></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 "UnsolicitedReferralAuthorizationResponseExample" </p></div><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-claim-type.html">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="http://example.org/new-payer/fhir/Patient/pat1">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/full</a> "New Health Plan"</p><p><b>requestor</b>: <a href="http://example.org/someProvider/fhir/Organization/good-health-clinic">http://example.org/someProvider/fhir/Organization/good-health-clinic</a></p><p><b>outcome</b>: complete</p><p><b>preAuthRef</b>: A1B2C3D4</p><blockquote><p><b>addItem</b></p><p><b>Authorized Date</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>Pre Authorized Issue Date</b>: 2005-05-02</p><p><b>Authorized Provider</b>: <a href="Practitioner-full.html">Practitioner/full</a> " BONE"</p><p><b>Item Trace Number</b>: id: A1B2C3D4</p><p><b>itemSequence</b>: 1</p><p><b>productOrService</b>: Consultation <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1365#3)</span></p><p><b>location</b>: 11 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-CMSPlaceofServiceCodes.html">CMS Place of Service Codes (POS)</a>#11)</span></p><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td>*</td><td></td><td>Submitted Amount <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-adjudication.html">Adjudication Value Codes</a>#submitted)</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>
      <extension
                 url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-reviewAction">
        <extension url="number">
          <valueString value="AUTH0001"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-reviewActionCode">
          <valueCodeableConcept>
            <coding>
              <system value="http://codesystem.x12.org/005010/306"/>
              <code value="A1"/>
              <display value="Certified in total"/>
            </coding>
          </valueCodeableConcept>
        </extension>
      </extension>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </coding>
      </category>
    </adjudication>
  </addItem>
</ClaimResponse>