Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0-preview - STU 2 United States of America flag

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

: PAS Claim Inquiry Example - JSON Representation

Page standards status: Informative

Raw json | Download

{
  "resourceType" : "Claim",
  "id" : "PASClaimInquiryExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PASClaimInquiryExample</b></p><a name=\"PASClaimInquiryExample\"> </a><a name=\"hcPASClaimInquiryExample\"> </a><a name=\"PASClaimInquiryExample-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>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>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 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}\">G0154</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>CertificationIssueDate</b>: 2019-07-01</p><p><b>CertificationEffectiveDate</b>: 2019-07-01</p><p><b>CertificationExpirationDate</b>: 2019-07-31</p><p><b>ReviewActionCode</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/306 A1}\">Certified in total</span></p><p><b>ProductOrServiceCodeEnd</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4190}\">B4190</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}\">B4184</span></p></blockquote></div>"
  },
  "identifier" : [
    {
      "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
      "value" : "111099",
      "assigner" : {
        "identifier" : {
          "system" : "http://example.org/USER_ASSIGNED",
          "value" : "9012345678"
        }
      }
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "professional"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    🔗 "reference" : "Patient/SubscriberExample"
  },
  "created" : "2019-07-20T11:01:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/InsurerExample"
  },
  "provider" : {
    🔗 "reference" : "Organization/UMOExample"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/InsuranceExample"
      }
    }
  ],
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1525",
                "code" : "HS",
                "display" : "Health Services Review"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1322",
                "code" : "I",
                "display" : "Initial"
              }
            ]
          }
        }
      ],
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "G0154"
          }
        ]
      }
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1525",
                "code" : "HS",
                "display" : "Health Services Review"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1322",
                "code" : "I",
                "display" : "Initial"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate",
          "valueDate" : "2019-07-01"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate",
          "valueDate" : "2019-07-01"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate",
          "valueDate" : "2019-07-31"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/306",
                "code" : "A1",
                "display" : "Certified in total"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
                "code" : "B4190"
              }
            ]
          }
        }
      ],
      "sequence" : 2,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "B4184"
          }
        ]
      }
    }
  ]
}