Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
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
{
"resourceType" : "Bundle",
"id" : "ReferralAuthorizationBundleExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"
]
},
"identifier" : {
"system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value" : "A12345"
},
"type" : "collection",
"timestamp" : "2005-05-02T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Claim/ReferralAuthorizationExample",
"resource" : {
"resourceType" : "Claim",
"id" : "ReferralAuthorizationExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"ReferralAuthorizationExample\"> </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 "ReferralAuthorizationExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim.html\">PAS Claim</a></p></div><p><b>LevelOfServiceCode</b>: Urgent <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1338#U)</span></p><p><b>identifier</b>: id:\u00a0111099</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>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td><a href=\"#PractitionerRole_ReferralPractitionerRoleExample\">See above (PractitionerRole/ReferralPractitionerRoleExample)</a></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td>G89.4 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G89.4)</span></td></tr></table><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>CareTeamSequence</b></td><td><b>DiagnosisSequence</b></td><td><b>Category</b></td><td><b>ProductOrService</b></td><td><b>Location[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>, , , , , , , , , </td><td>1</td><td>1</td><td>1</td><td>Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></td><td>Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1338",
"code" : "U",
"display" : "Urgent"
}
]
}
}
],
"identifier" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.usps.com/",
"code" : "MA"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment",
"valueString" : "223412"
}
],
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "111099",
"assigner" : {
"identifier" : {
"system" : "http://example.org/USER_ASSIGNED",
"value" : "9012345678"
}
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "professional"
}
]
},
"use" : "preauthorization",
"patient" : {
🔗 "reference" : "Patient/SubscriberExample"
},
"created" : "2005-05-02T11:01:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"provider" : {
🔗 "reference" : "Organization/UMOExample"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"careTeam" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
"valueBoolean" : true
}
],
"sequence" : 1,
"provider" : {
🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
}
}
],
"diagnosis" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
"valueDate" : "2021-05-10"
}
],
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G89.4"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/InsuranceExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
"valueIdentifier" : {
"system" : "http://example.org/ITEM_TRACE_NUMBER",
"value" : "1122334"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
"valueString" : "1122445"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
"valueString" : "9988311"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "SC",
"display" : "Specialty Care Review"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1322",
"code" : "I",
"display" : "Initial"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference" : {
🔗 "reference" : "ServiceRequest/ReferralRequestExample"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator",
"valueBoolean" : false
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1345",
"code" : "2",
"display" : "Newly Admitted"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1337",
"code" : "2",
"display" : "Intermediate Care Facility (ICF)"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit",
"valueDecimal" : 100
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"category" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11"
}
]
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/UMOExample",
"resource" : {
"resourceType" : "Organization",
"id" : "UMOExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"
]
},
"text" : {
"status" : "generated",
"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:\u00a0<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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "8189991234"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "X3"
}
]
}
],
"name" : "DR. JOE SMITH CORPORATION",
"address" : [
{
"line" : [
"111 1ST STREET"
],
"city" : "SAN DIEGO",
"state" : "CA",
"postalCode" : "92101",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/InsurerExample",
"resource" : {
"resourceType" : "Organization",
"id" : "InsurerExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"
]
},
"text" : {
"status" : "generated",
"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:\u00a0<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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "789312"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "PR"
}
]
}
],
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/InsuranceExample",
"resource" : {
"resourceType" : "Coverage",
"id" : "InsuranceExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
]
},
"text" : {
"status" : "generated",
"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>"
},
"status" : "active",
"beneficiary" : {
🔗 "reference" : "Patient/SubscriberExample"
},
"payor" : [
{
🔗 "reference" : "Organization/InsurerExample"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/SubscriberExample",
"resource" : {
"resourceType" : "Patient",
"id" : "SubscriberExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"
]
},
"text" : {
"status" : "extensions",
"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:\u00a012345678901</p><p><b>name</b>: JOE SMITH </p><p><b>gender</b>: male</p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/584",
"code" : "RU"
}
]
}
}
],
"identifier" : [
{
"system" : "http://example.org/MIN",
"value" : "12345678901"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
],
"gender" : "male"
}
},
{
"fullUrl" : "http://example.org/fhir/ServiceRequest/ReferralRequestExample",
"resource" : {
"resourceType" : "ServiceRequest",
"id" : "ReferralRequestExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ServiceRequest</b><a name=\"ReferralRequestExample\"> </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 ServiceRequest "ReferralRequestExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-servicerequest.html\">PAS Service Request</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: order</p><p><b>code</b>: Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></p><p><b>quantity</b>: 1 visit<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code 1 = '1')</span></p><p><b>subject</b>: <a href=\"#Patient_SubscriberExample\">See above (Patient/SubscriberExample)</a></p></div>"
},
"status" : "active",
"intent" : "order",
"code" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"quantityQuantity" : {
"value" : 1,
"unit" : "visit",
"system" : "http://unitsofmeasure.org",
"code" : "1"
},
"subject" : {
🔗 "reference" : "Patient/SubscriberExample"
}
}
},
{
"fullUrl" : "http://example.org/fhir/PractitionerRole/ReferralPractitionerRoleExample",
"resource" : {
"resourceType" : "PractitionerRole",
"id" : "ReferralPractitionerRoleExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: PractitionerRole</b><a name=\"ReferralPractitionerRoleExample\"> </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 PractitionerRole "ReferralPractitionerRoleExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-practitionerrole.html\">PAS PractitionerRole</a></p></div><p><b>practitioner</b>: <a href=\"#Practitioner_ReferralPractitionerExample\">See above (Practitioner/ReferralPractitionerExample)</a></p><p><b>location</b>: <a href=\"#Location_ReferralLocationExample\">See above (Location/ReferralLocationExample)</a></p></div>"
},
"practitioner" : {
🔗 "reference" : "Practitioner/ReferralPractitionerExample"
},
"location" : [
{
🔗 "reference" : "Location/ReferralLocationExample"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Practitioner/ReferralPractitionerExample",
"resource" : {
"resourceType" : "Practitioner",
"id" : "ReferralPractitionerExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Practitioner</b><a name=\"ReferralPractitionerExample\"> </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 Practitioner "ReferralPractitionerExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-practitioner.html\">PAS Practitioner</a></p></div><p><b>identifier</b>: id:\u00a0<a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-npi.html\">#</a>987654321</p><p><b>name</b>: SUSAN WATSON </p><p><b>telecom</b>: ph: 4029993456</p></div>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "987654321"
}
],
"name" : [
{
"family" : "WATSON",
"given" : [
"SUSAN"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "4029993456"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Location/ReferralLocationExample",
"resource" : {
"resourceType" : "Location",
"id" : "ReferralLocationExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Location</b><a name=\"ReferralLocationExample\"> </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 Location "ReferralLocationExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-location.html\">PAS Location Profile</a></p></div><p><b>name</b>: REFERRAL CLINIC</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>"
},
"name" : "REFERRAL CLINIC",
"address" : {
"line" : [
"111 1ST STREET"
],
"city" : "SAN DIEGO",
"state" : "CA",
"postalCode" : "92101",
"country" : "US"
}
}
}
]
}
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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