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

• Narrative Content
• XML
• JSON
• TTL

: Authorization Response with Practitioner Requestor Example - JSON Representation

Raw json | Download

{
  "resourceType" : "ClaimResponse",
  "id" : "PractitionerRequestorResponseExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorResponseExample</b></p><a name=\"PractitionerRequestorResponseExample\"> </a><a name=\"hcPractitionerRequestorResponseExample\"> </a><a name=\"PractitionerRequestorResponseExample-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>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole</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 --&gt; 2005-06-02</p><p><b>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --&gt; 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><ul><li>provider: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner SUSAN WATSON </a></li></ul></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><ul><li>productOrServiceCode: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</span></li><li>unitPrice: <span title=\"US Dollar\">$100.00</span> (USD)</li><li>quantity: 1</li></ul></blockquote><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></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" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/InsurerExample"
  },
  "requestor" : {
    🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
  },
  "request" : {
    🔗 "reference" : "Claim/ReferralAuthorizationExample"
  },
  "outcome" : "complete",
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
          "valuePeriod" : {
            "start" : "2005-05-02",
            "end" : "2005-06-02"
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
          "valueDate" : "2005-05-02"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
          "valuePeriod" : {
            "start" : "2005-05-02",
            "end" : "2005-06-02"
          }
        },
        {
          "extension" : [
            {
              "url" : "provider",
              "valueReference" : {
                🔗 "reference" : "Practitioner/ReferralPractitionerExample"
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider"
        },
        {
          "extension" : [
            {
              "url" : "productOrServiceCode",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://codesystem.x12.org/005010/1365",
                    "code" : "3",
                    "display" : "Consultation"
                  }
                ]
              }
            },
            {
              "url" : "unitPrice",
              "valueMoney" : {
                "value" : 100,
                "currency" : "USD"
              }
            },
            {
              "url" : "quantity",
              "valueQuantity" : {
                "value" : 1
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
        }
      ],
      "itemSequence" : 1,
      "adjudication" : [
        {
          "extension" : [
            {
              "extension" : [
                {
                  "url" : "number",
                  "valueString" : "AUTH0001"
                },
                {
                  "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-reviewAction"
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          }
        }
      ]
    }
  ]
}