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
Page standards status: Informative |
<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 --> 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>