Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2 United States of America flag

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

: PAS Inquiry Request Bundle Example - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="PASClaimInquiryBundleExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-request-bundle"/>
  </meta>
  <identifier>
    <system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
    <value value="5269367"/>
  </identifier>
  <type value="collection"/>
  <timestamp value="2005-05-02T11:01:00+05:00"/>
  <entry>
    <fullUrl value="http://example.org/fhir/Claim/PASClaimInquiryExample"/>
    <resource>
      <Claim>
        <id value="PASClaimInquiryExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"/>
        </meta>
        <text>
          <status value="extensions"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Claim</b><a name="PASClaimInquiryExample"> </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 &quot;PASClaimInquiryExample&quot; </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-claim-inquiry.html">PAS Claim Inquiry</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>: 2019-07-20 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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1322#I)</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: G0154 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (HCPCSReleaseCodeSets#G0154)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1322#I)</span></p><p><b>CertificationIssueDate</b>: 2019-07-01</p><p><b>CertificationEffectiveDate</b>: 2019-07-01</p><p><b>CertificationExpirationDate</b>: 2019-07-31</p><p><b>ReviewActionCode</b>: Certified in total <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (306#A1)</span></p><p><b>ProductOrServiceCodeEnd</b>: B4190 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (HCPCSReleaseCodeSets#B4190)</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: B4184 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (HCPCSReleaseCodeSets#B4184)</span></p></blockquote></div>
        </text>
        <identifier>
          <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
          <value value="111099"/>
          <assigner>
            <identifier>
              <system value="http://example.org/USER_ASSIGNED"/>
              <value value="9012345678"/>
            </identifier>
          </assigner>
        </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/SubscriberExample"/>
        </patient>
        <created value="2019-07-20T11:01:00+05:00"/>
        <insurer>🔗 
          <reference value="Organization/InsurerExample"/>
        </insurer>
        <provider>🔗 
          <reference value="Organization/UMOExample"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
          </coding>
        </priority>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>🔗 
            <reference value="Coverage/InsuranceExample"/>
          </coverage>
        </insurance>
        <item>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/1525"/>
                <code value="HS"/>
                <display value="Health Services Review"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/1322"/>
                <code value="I"/>
                <display value="Initial"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <sequence value="1"/>
          <productOrService>
            <coding>
              <system
                      value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
              <code value="G0154"/>
            </coding>
          </productOrService>
        </item>
        <item>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/1525"/>
                <code value="HS"/>
                <display value="Health Services Review"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/1322"/>
                <code value="I"/>
                <display value="Initial"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate">
            <valueDate value="2019-07-01"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate">
            <valueDate value="2019-07-01"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate">
            <valueDate value="2019-07-31"/>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/306"/>
                <code value="A1"/>
                <display value="Certified in total"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd">
            <valueCodeableConcept>
              <coding>
                <system
                        value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
                <code value="B4190"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <sequence value="2"/>
          <productOrService>
            <coding>
              <system
                      value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
              <code value="B4184"/>
            </coding>
          </productOrService>
        </item>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/UMOExample"/>
    <resource>
      <Organization>
        <id value="UMOExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"/>
        </meta>
        <text>
          <status value="generated"/>
          <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 &quot;UMOExample&quot; </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>
        </text>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="8189991234"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system value="https://codesystem.x12.org/005010/98"/>
            <code value="X3"/>
          </coding>
        </type>
        <name value="DR. JOE SMITH CORPORATION"/>
        <address>
          <line value="111 1ST STREET"/>
          <city value="SAN DIEGO"/>
          <state value="CA"/>
          <postalCode value="92101"/>
          <country value="US"/>
        </address>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/InsurerExample"/>
    <resource>
      <Organization>
        <id value="InsurerExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"/>
        </meta>
        <text>
          <status value="generated"/>
          <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 &quot;InsurerExample&quot; </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>
        </text>
        <identifier>
          <system value="http://hl7.org/fhir/sid/us-npi"/>
          <value value="789312"/>
        </identifier>
        <active value="true"/>
        <type>
          <coding>
            <system value="https://codesystem.x12.org/005010/98"/>
            <code value="PR"/>
          </coding>
        </type>
        <name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/InsuranceExample"/>
    <resource>
      <Coverage>
        <id value="InsuranceExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"/>
        </meta>
        <text>
          <status value="generated"/>
          <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 &quot;InsuranceExample&quot; </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>
        </text>
        <status value="active"/>
        <beneficiary>🔗 
          <reference value="Patient/SubscriberExample"/>
        </beneficiary>
        <payor>🔗 
          <reference value="Organization/InsurerExample"/>
        </payor>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Patient/SubscriberExample"/>
    <resource>
      <Patient>
        <id value="SubscriberExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
        </meta>
        <text>
          <status value="extensions"/>
          <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 &quot;SubscriberExample&quot; </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>
        </text>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus">
          <valueCodeableConcept>
            <coding>
              <system value="https://codesystem.x12.org/005010/584"/>
              <code value="RU"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <identifier>
          <system value="http://example.org/MIN"/>
          <value value="12345678901"/>
        </identifier>
        <name>
          <family value="SMITH"/>
          <given value="JOE"/>
        </name>
        <gender value="male"/>
      </Patient>
    </resource>
  </entry>
</Bundle>