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 - XML Representation

Page standards status: Informative

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<Claim xmlns="http://hl7.org/fhir">
  <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"><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>