Da Vinci Prior Authorization Support (PAS) FHIR IG
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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

: Referral Authorization Example - TTL Representation

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "ReferralAuthorizationExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><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>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1338"^^xsd:anyURI ] ;
fhir:code [ fhir:v "U" ] ;
fhir:display [ fhir:v "Urgent" ]       ] )     ]
  ] ) ; # 
  fhir:identifier ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://www.usps.com/"^^xsd:anyURI ] ;
fhir:code [ fhir:v "MA" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment"^^xsd:anyURI ] ;
fhir:value [ fhir:v "223412" ]     ] ) ;
fhir:system [ fhir:v "http://example.org/PATIENT_EVENT_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "111099" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [ fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ] ;
fhir:value [ fhir:v "9012345678" ]       ]     ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "professional" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
  ] ; # 
  fhir:created [ fhir:v "2005-05-02T11:01:00+05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:reference [ fhir:v "Organization/InsurerExample" ]
  ] ; # 
  fhir:provider [
fhir:reference [ fhir:v "Organization/UMOExample" ]
  ] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ]     ] )
  ] ; # 
  fhir:careTeam ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:reference [ fhir:v "PractitionerRole/ReferralPractitionerRoleExample" ]     ]
  ] ) ; # 
  fhir:diagnosis ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2021-05-10"^^xsd:date ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "G89.4" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/InsuranceExample" ]     ]
  ] ) ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ] ;
fhir:code [ fhir:v "SC" ] ;
fhir:display [ fhir:v "Specialty Care Review" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber"^^xsd:anyURI ] ;
fhir:value [
a fhir:Identifier ;
fhir:system [ fhir:v "http://example.org/ITEM_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "1122334" ]       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "1122445" ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "9988311" ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "ServiceRequest/ReferralRequestExample" ]       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator"^^xsd:anyURI ] ;
fhir:value [ fhir:v "false"^^xsd:boolean ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1345"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ] ;
fhir:display [ fhir:v "Newly Admitted" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1337"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ] ;
fhir:display [ fhir:v "Intermediate Care Facility (ICF)" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit"^^xsd:anyURI ] ;
fhir:value [ fhir:v "100"^^xsd:decimal ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:careTeamSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:diagnosisSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ] ;
fhir:code [ fhir:v "3" ] ;
fhir:display [ fhir:v "Consultation" ]       ] )     ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ] ;
fhir:code [ fhir:v "3" ] ;
fhir:display [ fhir:v "Consultation" ]       ] )     ] ;
fhir:location [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11" ]       ] )     ]
  ] ) . #