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 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

Example ClaimResponse: Unsolicited Prior Authorization example

Page standards status: Informative

Generated Narrative

Resource "UnsolicitedReferralAuthorizationResponseExample"

identifier: id: 111099

status: active

type: Professional (Claim Type Codes#professional)

use: preauthorization

patient: http://example.org/new-payer/fhir/Patient/pat1

created: 2005-05-02 11:02:00+0500

insurer: Organization/full "New Health Plan"

requestor: http://example.org/someProvider/fhir/Organization/good-health-clinic

outcome: complete

preAuthRef: A1B2C3D4

addItem

Authorized Date: 2005-05-02 --> 2005-06-02

Pre Authorized Issue Date: 2005-05-02

Authorized Provider: Practitioner/full " BONE"

Item Trace Number: id: A1B2C3D4

itemSequence: 1

productOrService: Consultation (1365#3)

location: 11 (CMS Place of Service Codes (POS)#11)

Adjudications

-ExtensionCategory
*Submitted Amount (Adjudication Value Codes#submitted)