Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot
Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot
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-referral",
"identifier" : {
"system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value" : "A12345"
},
"type" : "collection",
"timestamp" : "2005-05-02T11:01:00+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>identifier</b>: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Specialty Care Review <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/UM_REQUEST_CATEGORY_CODE code 'SC' = 'SC', given as 'Specialty Care 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>prescription</b>: see requested service extension</p><p><b>facility</b>: <a href=\"Location/1\">Location/1</a></p><h3>Diagnoses</h3><table class=\"grid\"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td><a href=\"Condition/1\">Condition/1</a></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></div>"
},
"identifier" : [
{
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "111099",
"assigner" : {
"reference" : "Organization/3"
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://example.org/UM_REQUEST_CATEGORY_CODE",
"code" : "SC",
"display" : "Specialty Care 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"
}
]
},
"prescription" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference" : {
"reference" : "ServiceRequest/1"
}
}
],
"display" : "see requested service extension"
},
"facility" : {
"reference" : "Location/1"
},
"diagnosis" : [
{
"sequence" : 1,
"diagnosisReference" : {
"reference" : "Condition/1"
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
"reference" : "Coverage/1"
}
}
]
}
},
{
"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>: ETIN = 8189991234</p><p><b>name</b>: JAMES GARDENER </p></div>"
},
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://example.org/IDENTIFICATION_CODE_QUALIFIER",
"code" : "46",
"display" : "ETIN"
}
]
},
"system" : "http://example.org/ETIN",
"value" : "8189991234"
}
],
"name" : [
{
"family" : "GARDENER",
"given" : [
"JAMES"
]
}
]
}
},
{
"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/Organization/3",
"resource" : {
"resourceType" : "Organization",
"id" : "3",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 3</p><p><b>identifier</b>: 9012345678</p></div>"
},
"identifier" : [
{
"system" : "http://example.org/USER_ASSIGNED",
"value" : "9012345678"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/ServiceRequest/1",
"resource" : {
"resourceType" : "ServiceRequest",
"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>intent</b>: plan</p><p><b>code</b>: Consultation <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/SERVICE_TYPE_CODE code '3' = '3', given as 'Consultation'})</span></p><p><b>quantity</b>: 1 VS</p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>performer</b>: <a href=\"PractitionerRole/2\">PractitionerRole/2</a></p></div>"
},
"status" : "active",
"intent" : "plan",
"code" : {
"coding" : [
{
"system" : "http://example.org/SERVICE_TYPE_CODE",
"code" : "3",
"display" : "Consultation"
}
]
},
"quantityQuantity" : {
"value" : 1,
"unit" : "VS"
},
"subject" : {
"reference" : "Patient/1"
},
"performer" : [
{
"reference" : "PractitionerRole/2"
}
]
}
},
{
"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"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Condition/1",
"resource" : {
"resourceType" : "Condition",
"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>code</b>: 410.90 <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/sid/icd-9-cm code '410.90' = '410.90)</span></p><p><b>subject</b>: <a href=\"Patient/1\">Patient/1</a></p><p><b>recordedDate</b>: Apr 30, 2005 12:00:00 AM</p></div>"
},
"code" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-9-cm",
"code" : "410.90"
}
]
},
"subject" : {
"reference" : "Patient/1"
},
"recordedDate" : "2005-04-30"
}
},
{
"fullUrl" : "http://example.org/fhir/PractitionerRole/2",
"resource" : {
"resourceType" : "PractitionerRole",
"id" : "2",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 2</p><p><b>practitioner</b>: <a href=\"Practitioner/2\">Practitioner/2</a></p><p><b>code</b>: Service Provider <span style=\"background: LightGoldenRodYellow\">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code 'SJ' = 'SJ', given as 'Service Provider'})</span></p></div>"
},
"practitioner" : {
"reference" : "Practitioner/2"
},
"code" : [
{
"coding" : [
{
"system" : "http://example.org/ENTITY_IDENTIFIER_CODE",
"code" : "SJ",
"display" : "Service Provider"
}
]
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Practitioner/2",
"resource" : {
"resourceType" : "Practitioner",
"id" : "2",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 2</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"
}
]
}
}
]
}
IG © 2019+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pas#0.1.0 based on FHIR 4.0.0. Generated 2019-08-05
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