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

PA Referral Response example - XML Representation

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Raw xml 


<Bundle xmlns="http://hl7.org/fhir">
  <id value="pa-response-example-referral"/>
  <type value="collection"/>
  <timestamp value="2005-05-02T11:02:00+05:00"/>
  <entry>
    <fullUrl value="http://example.org/fhir/ClaimResponse/1"/>
    <resource>
      <ClaimResponse>
        <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>: AUTH0001</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/claim-type code 'professional' = 'Professional)</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>requestor</b>: <a href="PractitionerRole/1">PractitionerRole/1</a></p><p><b>outcome</b>: complete</p></div>
        </text>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
          <valueCode value="A1"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate">
          <valuePeriod>
            <start value="2005-05-02"/>
            <end value="2005-06-02"/>
          </valuePeriod>
        </extension>
        <identifier>
          <system value="http://example.org/REVIEW_IDENTIFICATION_NUMBER"/>
          <value value="AUTH0001"/>
        </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/1"/>
        </patient>
        <created value="2019-07-20"/>
        <insurer>
          <reference value="Organization/1"/>
        </insurer>
        <requestor>
          <reference value="PractitionerRole/1"/>
        </requestor>
        <outcome value="complete"/>
      </ClaimResponse>
    </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>: ETIN = 8189991234</p><p><b>name</b>: JAMES GARDENER </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="8189991234"/>
        </identifier>
        <name>
          <family value="GARDENER"/>
          <given value="JAMES"/>
        </name>
      </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>
</Bundle>