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

Example Bundle: Referral Authorization Response Bundle Example

Bundle ReferralAuthorizationResponseBundleExample of type collection

Entry 1 - fullUrl = http://example.org/fhir/ClaimResponse/ReferralAuthorizationResponseExample

Resource ClaimResponse:

Generated Narrative: ClaimResponse

Resource ClaimResponse "ReferralAuthorizationResponseExample"

Profile: PAS Claim Response

identifier: id: 111099

status: ACTIVE

type: Professional (Claim Type Codes#professional)

use: PREAUTHORIZATION

patient: See above (Patient/SubscriberExample)

created: 2005-05-02 11:02:00+0500

insurer: See above (Organization/InsurerExample)

requestor: See above (Organization/UMOExample)

outcome: COMPLETE

item

ItemRequestedServiceDate: 2005-05-02 --> 2005-06-02

ItemPreAuthIssueDate: 2005-05-02

ItemPreAuthPeriod: 2005-05-02 --> 2005-06-02

ItemAuthorizedProvider

url

provider

value: Practitioner/ReferralPractitionerExample " WATSON"

ItemAuthorizedDetail

url

productOrServiceCode

value: Consultation (1365#3)

url

unitPrice

value: US$100.00 (USD)

url

quantity

value: 1

itemSequence: 1

Adjudications

-ExtensionCategory
*Submitted Amount (Adjudication Value Codes#submitted)

Entry 2 - fullUrl = http://example.org/fhir/Organization/UMOExample

Resource Organization:

Generated Narrative: Organization

Resource Organization "UMOExample"

Profile: PAS Requestor Organization

identifier: id: #8189991234

active: true

type: X3 (98#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

Resource Organization "InsurerExample"

Profile: PAS Insurer Organization

identifier: id: #789312

active: true

type: PR (98#PR)

name: MARYLAND CAPITAL INSURANCE COMPANY

Entry 4 - fullUrl = http://example.org/fhir/Patient/SubscriberExample

Resource Patient:

JOE SMITH Male, DoB: ( id: 12345678901)