Da Vinci Prior Authorization Support (PAS) FHIR IG
1.2.0-ballot - STU 1.2 US

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.2.0-ballot: STU 1.2 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

Example Bundle: Referral Authorization Response Bundle Example

Bundle ReferralAuthorizationResponseBundleExample of type collection

Entry 1 - Full URL = http://example.org/fhir/ClaimResponse/ReferralAuthorizationResponseExample

Resource ClaimResponse:

Generated Narrative

Resource "ReferralAuthorizationResponseExample"

Profile: PAS Claim Response

identifier: id: 111099

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREAUTHORIZATION

patient: Patient/SubscriberExample " SMITH"

created: 2005-05-02 11:02:00+0500

insurer: Organization/InsurerExample "MARYLAND CAPITAL INSURANCE COMPANY"

requestor: Organization/UMOExample "DR. JOE SMITH CORPORATION"

outcome: COMPLETE

item

ItemAuthorizedDate: 2005-05-02 --> 2005-06-02

ItemPreAuthIssueDate: 2005-05-02

ItemPreAuthPeriod: 2005-05-02 --> 2005-06-02

ItemAuthorizedProvider

value: Practitioner/ReferralPractitionerExample " WATSON"

ItemAuthorizedDetail

value: Consultation (1365#3)

value: $100.00 (USD)

value: 1

itemSequence: 1

Adjudications

-ExtensionCategory
*Submitted Amount (Adjudication Value Codes#submitted)

Entry 2 - Full URL = http://example.org/fhir/Organization/UMOExample

Resource Organization:

Generated Narrative

Resource "UMOExample"

Profile: PAS Requestor Organization

identifier: id: 8189991234

active: true

type: X3 (98#X3)

name: DR. JOE SMITH CORPORATION

address: 111 1ST STREET SAN DIEGO CA 92101 US

Entry 3 - Full URL = http://example.org/fhir/Organization/InsurerExample

Resource Organization:

Generated Narrative

Resource "InsurerExample"

Profile: PAS Insurer Organization

identifier: id: 789312

active: true

type: PR (98#PR)

name: MARYLAND CAPITAL INSURANCE COMPANY

Entry 4 - Full URL = http://example.org/fhir/Patient/SubscriberExample

Resource Patient:

JOE SMITH Male ( id: 12345678901)