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

PA Home Health Care Differential Request example - XML Representation

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Raw xml

<Bundle xmlns="http://hl7.org/fhir">
  <id value="pa-request-example-homehealthcare-differential"/>
  <meta>
    <security>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationValue"/>
      <code value="SUBSETTED"/>
    </security>
  </meta>
  <identifier>
    <system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
    <value value="B56789"/>
  </identifier>
  <type value="collection"/>
  <timestamp value="2005-05-02T14:30:00+05:00"/>
  <entry>
    <fullUrl value="http://example.org/fhir/Claim/1"/>
    <resource>
      <Claim>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://example.org/UM_REQUEST_CATEGORY_CODE"/>
            <code value="HS"/>
            <display value="Health Services Review"/>
          </coding>
        </type>
        <use value="preauthorization">
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
            <valueCode value="I"/>
          </extension>
        </use>
        <patient>
          <reference value="Patient/1"/>
        </patient>
        <created value="2019-07-20"/>
        <insurer>
          <reference value="Organization/1"/>
        </insurer>
        <provider>
          <reference value="PractitionerRole/1"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology/hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
            <display value="Normal"/>
          </coding>
        </priority>
        <facility>
          <reference value="Location/1"/>
        </facility>
        <supportingInfo>
          <sequence value="1"/>
          <category>
            <coding>
              <system
                      value="http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType"/>
              <code value="releaseOfInformation"/>
            </coding>
          </category>
          <valueString value="Y"/>
        </supportingInfo>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <reference value="Coverage/1"/>
          </coverage>
        </insurance>
        <item>
          <modifierExtension
                             url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCancelled">
            <valueBoolean value="true"/>
          </modifierExtension>
          <sequence value="2"/>
          <productOrService>
            <coding>
              <system value="http://www.ama-assn.org/go/cpt"/>
              <code value="B4224"/>
            </coding>
          </productOrService>
        </item>
        <item>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged">
            <valueCode value="added"/>
          </extension>
          <sequence value="3"/>
          <productOrService>
            <coding>
              <system value="http://www.ama-assn.org/go/cpt"/>
              <code value="B4185"/>
            </coding>
          </productOrService>
        </item>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/1"/>
    <resource>
      <Organization>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="46"/>
              <display value="ETIN"/>
            </coding>
          </type>
          <system value="http://example.org/ETIN"/>
          <value value="789312"/>
        </identifier>
        <type>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="X3"/>
            <display value="Utilization Management Organization"/>
          </coding>
        </type>
        <name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/PractitionerRole/1"/>
    <resource>
      <PractitionerRole>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <practitioner>
          <reference value="Practitioner/1"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="1P"/>
            <display value="Provider"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/1"/>
    <resource>
      <Practitioner>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="34"/>
              <display value="SSN"/>
            </coding>
          </type>
          <system value="http://example.org/SSN"/>
          <value value="987654321"/>
        </identifier>
        <name>
          <family value="WATSON"/>
          <given value="SUSAN"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="4029993456"/>
        </telecom>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/1"/>
    <resource>
      <Coverage>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <status value="active"/>
      <!--  This is actual the subscriber but beneficiary is mandatory  -->
        <beneficiary>
          <reference value="Patient/1"/>
        </beneficiary>
      <!--  Payor is mandatory but we don't actually have one so the insurer organization is specified here  -->
        <payor>
          <reference value="Organization/1"/>
        </payor>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Patient/1"/>
    <resource>
      <Patient>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="MI"/>
              <display value="Member Identification Number"/>
            </coding>
          </type>
          <system value="http://example.org/MIN"/>
          <value value="12345678901"/>
        </identifier>
        <name>
          <family value="SMITH"/>
          <given value="JOE"/>
        </name>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Location/1"/>
    <resource>
      <Location>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <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>
        </text>
        <type>
          <coding>
            <system value="http://example.org/Place-of-Service-Codes"/>
            <code value="11"/>
          </coding>
        </type>
      </Location>
    </resource>
  </entry>
</Bundle>