This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Bundle ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "MedicalServicesAuthorizationBundleExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle> ] )
] ; #
fhir:identifier [
fhir:system [ fhir:v "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "5269367" ]
] ; #
fhir:type [ fhir:v "collection"] ; #
fhir:timestamp [ fhir:v "2005-05-02T11:01:00+05:00"^^xsd:dateTime] ; #
fhir:entry ( [
fhir:fullUrl [ fhir:v "http://example.org/fhir/Claim/MedicalServicesAuthorizationExample"^^xsd:anyURI ] ;
( fhir:resource <http://example.org/fhir/Claim/MedicalServicesAuthorizationExample> )
] [
fhir:fullUrl [ fhir:v "http://example.org/fhir/Organization/UMOExample"^^xsd:anyURI ] ;
( fhir:resource <http://example.org/fhir/Organization/UMOExample> )
] [
fhir:fullUrl [ fhir:v "http://example.org/fhir/Organization/InsurerExample"^^xsd:anyURI ] ;
( fhir:resource <http://example.org/fhir/Organization/InsurerExample> )
] [
fhir:fullUrl [ fhir:v "http://example.org/fhir/Coverage/InsuranceExample"^^xsd:anyURI ] ;
( fhir:resource <http://example.org/fhir/Coverage/InsuranceExample> )
] [
fhir:fullUrl [ fhir:v "http://example.org/fhir/Patient/SubscriberExample"^^xsd:anyURI ] ;
( fhir:resource <http://example.org/fhir/Patient/SubscriberExample> )
] ) . #
<http://example.org/fhir/Claim/MedicalServicesAuthorizationExample> a fhir:Claim ;
fhir:id [ fhir:v "MedicalServicesAuthorizationExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"MedicalServicesAuthorizationExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Claim "MedicalServicesAuthorizationExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim.html\">PAS Claim</a></p></div><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"#Patient_SubscriberExample\">See above (Patient/SubscriberExample)</a></p><p><b>created</b>: 2005-05-02 11:01:00+0500</p><p><b>insurer</b>: <a href=\"#Organization_InsurerExample\">See above (Organization/InsurerExample)</a></p><p><b>provider</b>: <a href=\"#Organization_UMOExample\">See above (Organization/UMOExample)</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"#Coverage_InsuranceExample\">See above (Coverage/InsuranceExample)</a></td></tr></table><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>ProductOrService</b></td><td><b>Serviced[x]</b></td><td><b>Location[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>, , , </td><td>1</td><td>Medical Care <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#1)</span></td><td>Established Office Visit <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#99212)</span></td><td>2005-05-10</td><td>11 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#11)</span></td></tr></table></div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://example.org/PATIENT_EVENT_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "111099" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [ fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ] ;
fhir:value [ fhir:v "9012345678" ] ] ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "professional" ] ] )
] ; #
fhir:use [ fhir:v "preauthorization"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
] ; #
fhir:created [ fhir:v "2005-05-02T11:01:00+05:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/InsurerExample" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/UMOExample" ]
] ; #
fhir:priority [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ] ] )
] ; #
fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/InsuranceExample" ] ]
] ) ; #
fhir:item ( [
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ] ;
fhir:code [ fhir:v "IN" ] ;
fhir:display [ fhir:v "Initial Medical Services Reservation" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "1122344" ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "33441122" ] ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1" ] ;
fhir:display [ fhir:v "Medical Care" ] ] ) ] ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ;
fhir:code [ fhir:v "99212" ] ;
fhir:display [ fhir:v "Established Office Visit" ] ] ) ] ;
fhir:serviced [ fhir:v "2005-05-10"^^xsd:date ] ;
fhir:location [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11" ] ] ) ]
] ) . #
<http://example.org/fhir/Organization/UMOExample> a fhir:Organization ;
fhir:id [ fhir:v "UMOExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"UMOExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Organization "UMOExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-requestor.html\">PAS Requestor Organization</a></p></div><p><b>identifier</b>: id: <a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-npi.html\">#</a>8189991234</p><p><b>active</b>: true</p><p><b>type</b>: X3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (98#X3)</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ] ;
fhir:value [ fhir:v "8189991234" ]
] ) ; #
fhir:active [ fhir:v "true"^^xsd:boolean] ; #
fhir:type ( [
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/98"^^xsd:anyURI ] ;
fhir:code [ fhir:v "X3" ] ] )
] ) ; #
fhir:name [ fhir:v "DR. JOE SMITH CORPORATION"] ; #
fhir:address ( [
( fhir:line [ fhir:v "111 1ST STREET" ] ) ;
fhir:city [ fhir:v "SAN DIEGO" ] ;
fhir:state [ fhir:v "CA" ] ;
fhir:postalCode [ fhir:v "92101" ] ;
fhir:country [ fhir:v "US" ]
] ) . #
<http://example.org/fhir/Organization/InsurerExample> a fhir:Organization ;
fhir:id [ fhir:v "InsurerExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"InsurerExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Organization "InsurerExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-insurer.html\">PAS Insurer Organization</a></p></div><p><b>identifier</b>: id: <a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-npi.html\">#</a>789312</p><p><b>active</b>: true</p><p><b>type</b>: PR <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (98#PR)</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ] ;
fhir:value [ fhir:v "789312" ]
] ) ; #
fhir:active [ fhir:v "true"^^xsd:boolean] ; #
fhir:type ( [
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/98"^^xsd:anyURI ] ;
fhir:code [ fhir:v "PR" ] ] )
] ) ; #
fhir:name [ fhir:v "MARYLAND CAPITAL INSURANCE COMPANY"] . #
<http://example.org/fhir/Coverage/InsuranceExample> a fhir:Coverage ;
fhir:id [ fhir:v "InsuranceExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Coverage</b><a name=\"InsuranceExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Coverage "InsuranceExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-coverage.html\">PAS Coverage</a></p></div><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"#Patient_SubscriberExample\">See above (Patient/SubscriberExample)</a></p><p><b>payor</b>: <a href=\"#Organization_InsurerExample\">See above (Organization/InsurerExample)</a></p></div>"
] ; #
fhir:status [ fhir:v "active"] ; #
fhir:beneficiary [
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
] ; #
fhir:payor ( [
fhir:reference [ fhir:v "Organization/InsurerExample" ]
] ) . #
<http://example.org/fhir/Patient/SubscriberExample> a fhir:Patient ;
fhir:id [ fhir:v "SubscriberExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Patient</b><a name=\"SubscriberExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Patient "SubscriberExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-subscriber.html\">PAS Subscriber Patient</a></p></div><p><b>MilitaryStatus</b>: RU <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (584#RU)</span></p><p><b>identifier</b>: id: 12345678901</p><p><b>name</b>: JOE SMITH </p><p><b>gender</b>: male</p></div>"
] ; #
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/584"^^xsd:anyURI ] ;
fhir:code [ fhir:v "RU" ] ] ) ]
] ) ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://example.org/MIN"^^xsd:anyURI ] ;
fhir:value [ fhir:v "12345678901" ]
] ) ; #
fhir:name ( [
fhir:family [ fhir:v "SMITH" ] ;
( fhir:given [ fhir:v "JOE" ] )
] ) ; #
fhir:gender [ fhir:v "male"] . #
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.0.1 based on FHIR 4.0.1. Generated 2023-12-01
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