This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0: 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
Generated Narrative: Bundle PASClaimInquiryResponseBundleExample
Bundle PASClaimInquiryResponseBundleExample of type collection
Entry 1 - fullUrl = http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample
Resource ClaimResponse:
Generated Narrative: ClaimResponse PASClaimInquiryResponseExample
identifier:
http://example.org/PATIENT_EVENT_TRACE_NUMBER
/111099status: Active
type: Professional
use: Preauthorization
patient: JOE SMITH Male, DoB Unknown ( Member Number)
created: 2019-07-20 11:01:00+0500
insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY
outcome: complete
item
ItemRequestedServiceDate: 2005-05-02 --> 2005-06-02
itemSequence: 1
Adjudications
Extension Category Submitted Amount Insurances
Sequence Focal Coverage 1 true Coverage: status = active; subscriberId = 1122334455; relationship = Self
Entry 2 - fullUrl = http://example.org/fhir/Organization/UMOExample
Resource Organization:
Generated Narrative: Organization UMOExample
identifier: United States National Provider Identifier/8189991234
active: true
type: X3
name: DR. JOE SMITH CORPORATION
Contacts
Address 111 1ST STREET SAN DIEGO CA 92101 US
Entry 3 - fullUrl = http://example.org/fhir/Organization/InsurerExample
Resource Organization:
Generated Narrative: Organization InsurerExample
identifier: United States National Provider Identifier/1234567893
active: true
type: PR
name: MARYLAND CAPITAL INSURANCE COMPANY
Entry 4 - fullUrl = http://example.org/fhir/Coverage/InsuranceExample
Resource Coverage:
Generated Narrative: Coverage InsuranceExample
status: Active
subscriberId: 1122334455
beneficiary: JOE SMITH Male, DoB Unknown ( Member Number)
relationship: Self
Entry 5 - fullUrl = http://example.org/fhir/Patient/SubscriberExample
Resource Patient:
Generated Narrative: Patient SubscriberExample
JOE SMITH Male, DoB Unknown ( Member Number)
RU
Entry 6 - fullUrl = http://example.org/fhir/Claim/ReferralAuthorizationExample
Resource Claim:
Generated Narrative: Claim ReferralAuthorizationExample
LevelOfServiceCode: Urgent
identifier:
http://example.org/PATIENT_EVENT_TRACE_NUMBER
/111099status: Active
type: Professional
use: Preauthorization
patient: JOE SMITH Male, DoB Unknown ( Member Number)
created: 2005-05-02 11:01:00+0500
insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY
provider: Organization DR. JOE SMITH CORPORATION
priority: Normal
CareTeams
Extension Sequence Provider 1 PractitionerRole Diagnoses
Extension Sequence Diagnosis[x] 1 Chronic pain syndrome Insurances
Sequence Focal Coverage 1 true Coverage: status = active; subscriberId = 1122334455; relationship = Self item
ServiceItemRequestType: Specialty Care Review
CertificationType: Initial
ItemTraceNumber:
http://example.org/ITEM_TRACE_NUMBER
/1122334AuthorizationNumber: 1122445
AdministrationReferenceNumber: 9988311
RequestedService: ServiceRequest Consultation
EPSDTIndicator: false
NursingHomeResidentialStatus: Newly Admitted
NursingHomeLevelOfCare: Intermediate Care Facility (ICF)
RevenueUnitRateLimit: 100
sequence: 1
careTeamSequence: 1
diagnosisSequence: 1
category: Consultation
productOrService: Consultation
location: 11