This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
{ "resourceType" : "Bundle", "id" : "pa-request-example-homehealthcare-differential", "meta" : { "security" : [ { "system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationValue", "code" : "SUBSETTED" } ] }, "identifier" : { "system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER", "value" : "B56789" }, "type" : "collection", "timestamp" : "2005-05-02T14:30:00+05:00", "entry" : [ { "fullUrl" : "http://example.org/fhir/Claim/1", "resource" : { "resourceType" : "Claim", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>type</b>: Health Services Review <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/UM_REQUEST_CATEGORY_CODE code 'HS' = 'HS', given as 'Health Services Review'})</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>created</b>: Jul 20, 2019 12:00:00 AM</p><p><b>insurer</b>: <a href=\"Organization/1\">Organization/1</a></p><p><b>provider</b>: <a href=\"PractitionerRole/1\">PractitionerRole/1</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology/hl7.org/CodeSystem/processpriority code 'normal' = 'normal', given as 'Normal'})</span></p><p><b>facility</b>: <a href=\"Location/1\">Location/1</a></p><h3>SupportingInfos</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1</td><td>Release Of Information <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType code 'releaseOfInformation' = 'Release Of Information)</span></td><td>Y</td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href=\"Coverage/1\">Coverage/1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: B4224 <span style=\"background: LightGoldenRodYellow\">(Details : {http://www.ama-assn.org/go/cpt code 'B4224' = 'B4224)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: B4185 <span style=\"background: LightGoldenRodYellow\">(Details : {http://www.ama-assn.org/go/cpt code 'B4185' = 'B4185)</span></p></blockquote></div>" }, "status" : "active", "type" : { "coding" : [ { "system" : "http://example.org/UM_REQUEST_CATEGORY_CODE", "code" : "HS", "display" : "Health Services Review" } ] }, "use" : "preauthorization", "_use" : { "extension" : [ { "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType", "valueCode" : "I" } ] }, "patient" : { "reference" : "Patient/1" }, "created" : "2019-07-20", "insurer" : { "reference" : "Organization/1" }, "provider" : { "reference" : "PractitionerRole/1" }, "priority" : { "coding" : [ { "system" : "http://terminology/hl7.org/CodeSystem/processpriority", "code" : "normal", "display" : "Normal" } ] }, "facility" : { "reference" : "Location/1" }, "supportingInfo" : [ { "sequence" : 1, "category" : { "coding" : [ { "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType", "code" : "releaseOfInformation" } ] }, "valueString" : "Y" } ], "insurance" : [ { "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/1" } } ], "item" : [ { "modifierExtension" : [ { "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCancelled", "valueBoolean" : true } ], "sequence" : 2, "productOrService" : { "coding" : [ { "system" : "http://www.ama-assn.org/go/cpt", "code" : "B4224" } ] } }, { "extension" : [ { "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged", "valueCode" : "added" } ], "sequence" : 3, "productOrService" : { "coding" : [ { "system" : "http://www.ama-assn.org/go/cpt", "code" : "B4185" } ] } } ] } }, { "fullUrl" : "http://example.org/fhir/Organization/1", "resource" : { "resourceType" : "Organization", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: ETIN = 789312</p><p><b>type</b>: Utilization Management Organization <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code 'X3' = 'X3', given as 'Utilization Management Organization'})</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>" }, "identifier" : [ { "type" : { "coding" : [ { "system" : "http://example.org/IDENTIFICATION_CODE_QUALIFIER", "code" : "46", "display" : "ETIN" } ] }, "system" : "http://example.org/ETIN", "value" : "789312" } ], "type" : [ { "coding" : [ { "system" : "http://example.org/ENTITY_IDENTIFIER_CODE", "code" : "X3", "display" : "Utilization Management Organization" } ] } ], "name" : "MARYLAND CAPITAL INSURANCE COMPANY" } }, { "fullUrl" : "http://example.org/fhir/PractitionerRole/1", "resource" : { "resourceType" : "PractitionerRole", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>practitioner</b>: <a href=\"Practitioner/1\">Practitioner/1</a></p><p><b>code</b>: Provider <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code '1P' = '1P', given as 'Provider'})</span></p></div>" }, "practitioner" : { "reference" : "Practitioner/1" }, "code" : [ { "coding" : [ { "system" : "http://example.org/ENTITY_IDENTIFIER_CODE", "code" : "1P", "display" : "Provider" } ] } ] } }, { "fullUrl" : "http://example.org/fhir/Practitioner/1", "resource" : { "resourceType" : "Practitioner", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: SSN = 987654321</p><p><b>name</b>: SUSAN WATSON </p><p><b>telecom</b>: ph: 4029993456</p></div>" }, "identifier" : [ { "type" : { "coding" : [ { "system" : "http://example.org/IDENTIFICATION_CODE_QUALIFIER", "code" : "34", "display" : "SSN" } ] }, "system" : "http://example.org/SSN", "value" : "987654321" } ], "name" : [ { "family" : "WATSON", "given" : [ "SUSAN" ] } ], "telecom" : [ { "system" : "phone", "value" : "4029993456" } ] } }, { "fullUrl" : "http://example.org/fhir/Coverage/1", "resource" : { "resourceType" : "Coverage", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>payor</b>: <a href=\"Organization/1\">Organization/1</a></p></div>" }, "status" : "active", "beneficiary" : { "reference" : "Patient/1" }, "payor" : [ { "reference" : "Organization/1" } ] } }, { "fullUrl" : "http://example.org/fhir/Patient/1", "resource" : { "resourceType" : "Patient", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: Member Identification Number = 12345678901</p><p><b>name</b>: JOE SMITH </p></div>" }, "identifier" : [ { "type" : { "coding" : [ { "system" : "http://example.org/IDENTIFICATION_CODE_QUALIFIER", "code" : "MI", "display" : "Member Identification Number" } ] }, "system" : "http://example.org/MIN", "value" : "12345678901" } ], "name" : [ { "family" : "SMITH", "given" : [ "JOE" ] } ] } }, { "fullUrl" : "http://example.org/fhir/Location/1", "resource" : { "resourceType" : "Location", "id" : "1", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>type</b>: 11 <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/Place-of-Service-Codes code '11' = '11)</span></p></div>" }, "type" : [ { "coding" : [ { "system" : "http://example.org/Place-of-Service-Codes", "code" : "11" } ] } ] } } ] }