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
<Bundle xmlns="http://hl7.org/fhir">
<id value="ReferralAuthorizationBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"/>
</meta>
<identifier>
<system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
<value value="A12345"/>
</identifier>
<type value="collection"/>
<timestamp value="2005-05-02T11:01:00+05:00"/>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/ReferralAuthorizationExample"/>
<resource>
<Claim>
<id value="ReferralAuthorizationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="extensions"/>
<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: 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>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>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1338"/>
<code value="U"/>
<display value="Urgent"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction">
<valueCodeableConcept>
<coding>
<system value="https://www.usps.com/"/>
<code value="MA"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment">
<valueString value="223412"/>
</extension>
<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="2005-05-02T11:01:00+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>
<careTeam>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope">
<valueBoolean value="true"/>
</extension>
<sequence value="1"/>
<provider>🔗
<reference
value="PractitionerRole/ReferralPractitionerRoleExample"/>
</provider>
</careTeam>
<diagnosis>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate">
<valueDate value="2021-05-10"/>
</extension>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G89.4"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<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-itemTraceNumber">
<valueIdentifier>
<system value="http://example.org/ITEM_TRACE_NUMBER"/>
<value value="1122334"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber">
<valueString value="1122445"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber">
<valueString value="9988311"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="SC"/>
<display value="Specialty Care 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-requestedService">
<valueReference>🔗
<reference value="ServiceRequest/ReferralRequestExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator">
<valueBoolean value="false"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1345"/>
<code value="2"/>
<display value="Newly Admitted"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1337"/>
<code value="2"/>
<display value="Intermediate Care Facility (ICF)"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit">
<valueDecimal value="100"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</category>
<productOrService>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</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 "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>
</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 "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>
</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 "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>
</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 "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>
</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>
<entry>
<fullUrl
value="http://example.org/fhir/ServiceRequest/ReferralRequestExample"/>
<resource>
<ServiceRequest>
<id value="ReferralRequestExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<status value="active"/>
<intent value="order"/>
<code>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</code>
<quantityQuantity>
<value value="1"/>
<unit value="visit"/>
<system value="http://unitsofmeasure.org"/>
<code value="1"/>
</quantityQuantity>
<subject>🔗
<reference value="Patient/SubscriberExample"/>
</subject>
</ServiceRequest>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/PractitionerRole/ReferralPractitionerRoleExample"/>
<resource>
<PractitionerRole>
<id value="ReferralPractitionerRoleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<practitioner>🔗
<reference value="Practitioner/ReferralPractitionerExample"/>
</practitioner>
<location>🔗
<reference value="Location/ReferralLocationExample"/>
</location>
</PractitionerRole>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Practitioner/ReferralPractitionerExample"/>
<resource>
<Practitioner>
<id value="ReferralPractitionerExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner"/>
</meta>
<text>
<status value="generated"/>
<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: <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>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="987654321"/>
</identifier>
<name>
<family value="WATSON"/>
<given value="SUSAN"/>
</name>
<telecom>
<system value="phone"/>
<value value="4029993456"/>
</telecom>
</Practitioner>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Location/ReferralLocationExample"/>
<resource>
<Location>
<id value="ReferralLocationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<name value="REFERRAL CLINIC"/>
<address>
<line value="111 1ST STREET"/>
<city value="SAN DIEGO"/>
<state value="CA"/>
<postalCode value="92101"/>
<country value="US"/>
</address>
</Location>
</resource>
</entry>
</Bundle>
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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