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

: Authorization Response with Practitioner Requestor Example - XML Representation

Page standards status: Informative

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="PractitionerRequestorResponseExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </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="2005-05-02T11:02:00+05:00"/>
  <insurer>🔗 
    <reference value="Organization/InsurerExample"/>
  </insurer>
  <requestor>🔗 
    <reference value="PractitionerRole/ReferralPractitionerRoleExample"/>
  </requestor>
  <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>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate">
      <valueDate value="2005-05-02"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod">
      <valuePeriod>
        <start value="2005-05-02"/>
        <end value="2005-06-02"/>
      </valuePeriod>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider">
      <extension url="provider">
        <valueReference>🔗 
          <reference value="Practitioner/ReferralPractitionerExample"/>
        </valueReference>
      </extension>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail">
      <extension url="productOrServiceCode">
        <valueCodeableConcept>
          <coding>
            <system value="https://codesystem.x12.org/005010/1365"/>
            <code value="3"/>
            <display value="Consultation"/>
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="unitPrice">
        <valueMoney>
          <value value="100"/>
          <currency value="USD"/>
        </valueMoney>
      </extension>
      <extension url="quantity">
        <valueQuantity>
          <value value="1"/>
        </valueQuantity>
      </extension>
    </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>
</ClaimResponse>