Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0-preview - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0-preview - STU 2
This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0-preview: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.1. For a full list of available versions, see the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="PASClaimInquiryResponseBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"/>
</meta>
<identifier>
<system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
<value value="5269367"/>
</identifier>
<type value="collection"/>
<timestamp value="2005-05-02T11:01:00+05:00"/>
<entry>
<fullUrl
value="http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample"/>
<resource>
<ClaimResponse>
<id value="PASClaimInquiryResponseExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ClaimResponse_PASClaimInquiryResponseExample"> </a><p class="res-header-id"><b>Generated Narrative: ClaimResponse PASClaimInquiryResponseExample</b></p><a name="PASClaimInquiryResponseExample"> </a><a name="hcPASClaimInquiryResponseExample"> </a><a name="PASClaimInquiryResponseExample-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="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>request</b>: <a href="Claim-ReferralAuthorizationExample.html">Claim: extension = Urgent; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --> 2005-06-02</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td/><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></blockquote><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-InsuranceExample.html">Coverage: status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table></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="Patient/SubscriberExample"/>
</patient>
<created value="2019-07-20T11:01:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<request>🔗
<reference value="Claim/ReferralAuthorizationExample"/>
</request>
<outcome value="complete"/>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate">
<valuePeriod>
<start value="2005-05-02"/>
<end value="2005-06-02"/>
</valuePeriod>
</extension>
<itemSequence value="1"/>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
<extension url="number">
<valueString value="AUTH0001"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
<valueCodeableConcept>
<coding>
<system value="https://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>
</item>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
</ClaimResponse>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/UMOExample"/>
<resource>
<Organization>
<id value="UMOExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_UMOExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization UMOExample</b></p><a name="UMOExample"> </a><a name="hcUMOExample"> </a><a name="UMOExample-en-US"> </a><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.3.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 X3}">X3</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="8189991234"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="X3"/>
</coding>
</type>
<name value="DR. JOE SMITH CORPORATION"/>
<address>
<line value="111 1ST STREET"/>
<city value="SAN DIEGO"/>
<state value="CA"/>
<postalCode value="92101"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/InsurerExample"/>
<resource>
<Organization>
<id value="InsurerExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_InsurerExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization InsurerExample</b></p><a name="InsurerExample"> </a><a name="hcInsurerExample"> </a><a name="InsurerExample-en-US"> </a><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.3.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 PR}">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234567893"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="PR"/>
</coding>
</type>
<name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/InsuranceExample"/>
<resource>
<Coverage>
<id value="InsuranceExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_InsuranceExample"> </a><p class="res-header-id"><b>Generated Narrative: Coverage InsuranceExample</b></p><a name="InsuranceExample"> </a><a name="hcInsuranceExample"> </a><a name="InsuranceExample-en-US"> </a><p><b>status</b>: Active</p><p><b>subscriberId</b>: 1122334455</p><p><b>beneficiary</b>: <a href="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}, {https://codesystem.x12.org/005010/1069 18}">Self</span></p><p><b>payor</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p></div>
</text>
<status value="active"/>
<subscriberId value="1122334455"/>
<beneficiary>🔗
<reference value="Patient/SubscriberExample"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
</coding>
<coding>
<system value="https://codesystem.x12.org/005010/1069"/>
<code value="18"/>
</coding>
</relationship>
<payor>🔗
<reference value="Organization/InsurerExample"/>
</payor>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/SubscriberExample"/>
<resource>
<Patient>
<id value="SubscriberExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_SubscriberExample"> </a><p class="res-header-id"><b>Generated Narrative: Patient SubscriberExample</b></p><a name="SubscriberExample"> </a><a name="hcSubscriberExample"> </a><a name="SubscriberExample-en-US"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="A patient's military status."><a href="StructureDefinition-extension-militaryStatus.html"/></td><td colspan="3"><span title="Codes:{https://codesystem.x12.org/005010/584 RU}">RU</span></td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/584"/>
<code value="RU"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<system value="http://example.org/MIN"/>
<value value="12345678901"/>
</identifier>
<name>
<family value="SMITH"/>
<given value="JOE"/>
</name>
<gender value="male"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/ReferralAuthorizationExample"/>
<resource>
<Claim>
<id value="ReferralAuthorizationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_ReferralAuthorizationExample"> </a><p class="res-header-id"><b>Generated Narrative: Claim ReferralAuthorizationExample</b></p><a name="ReferralAuthorizationExample"> </a><a name="hcReferralAuthorizationExample"> </a><a name="ReferralAuthorizationExample-en-US"> </a><p><b>LevelOfServiceCode</b>: <span title="Codes:{https://codesystem.x12.org/005010/1338 U}">Urgent</span></p><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="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2005-05-02 11:01:00+0500</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>provider</b>: <a href="Organization-UMOExample.html">Organization DR. JOE SMITH CORPORATION</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><a href="PractitionerRole-ReferralPractitionerRoleExample.html">PractitionerRole</a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm G89.4}">Chronic pain syndrome</span></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style="display: none">*</td><td>1</td><td>true</td><td><a href="Coverage-InsuranceExample.html">Coverage: status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 SC}">Specialty Care Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>ItemTraceNumber</b>: <code>http://example.org/ITEM_TRACE_NUMBER</code>/1122334</p><p><b>AuthorizationNumber</b>: 1122445</p><p><b>AdministrationReferenceNumber</b>: 9988311</p><p><b>RequestedService</b>: <a href="ServiceRequest-ReferralRequestExample.html">ServiceRequest Consultation</a></p><p><b>EPSDTIndicator</b>: false</p><p><b>NursingHomeResidentialStatus</b>: <span title="Codes:{https://codesystem.x12.org/005010/1345 2}">Newly Admitted</span></p><p><b>NursingHomeLevelOfCare</b>: <span title="Codes:{https://codesystem.x12.org/005010/1337 2}">Intermediate Care Facility (ICF)</span></p><p><b>RevenueUnitRateLimit</b>: 100</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>productOrService</b>: <span title="Codes:{https://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></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1338"/>
<code value="U"/>
<display value="Urgent"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction">
<valueCodeableConcept>
<coding>
<system value="https://www.usps.com/"/>
<code value="MA"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment">
<valueString value="223412"/>
</extension>
<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="Patient/SubscriberExample"/>
</patient>
<created value="2005-05-02T11:01:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<provider>🔗
<reference value="Organization/UMOExample"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<careTeam>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope">
<valueBoolean value="true"/>
</extension>
<sequence value="1"/>
<provider>🔗
<reference
value="PractitionerRole/ReferralPractitionerRoleExample"/>
</provider>
</careTeam>
<diagnosis>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate">
<valueDate value="2021-05-10"/>
</extension>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G89.4"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="SC"/>
<display value="Specialty Care Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber">
<valueIdentifier>
<system value="http://example.org/ITEM_TRACE_NUMBER"/>
<value value="1122334"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber">
<valueString value="1122445"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber">
<valueString value="9988311"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
<valueReference>🔗
<reference value="ServiceRequest/ReferralRequestExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator">
<valueBoolean value="false"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1345"/>
<code value="2"/>
<display value="Newly Admitted"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1337"/>
<code value="2"/>
<display value="Intermediate Care Facility (ICF)"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit">
<valueDecimal value="100"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</category>
<productOrService>
<coding>
<system value="https://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>
</item>
</Claim>
</resource>
</entry>
</Bundle>
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.1.0-preview based on FHIR 4.0.1. Generated 2024-09-26
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