Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
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
{
"resourceType" : "Bundle",
"id" : "ReferralPendingAuthorizationResponseBundleExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"
]
},
"type" : "collection",
"timestamp" : "2005-05-02T11:02:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/ClaimResponse/PractitionerRequestorPendingResponseExample",
"resource" : {
"resourceType" : "ClaimResponse",
"id" : "PractitionerRequestorPendingResponseExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_PractitionerRequestorPendingResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorPendingResponseExample</b></p><a name=\"PractitionerRequestorPendingResponseExample\"> </a><a name=\"hcPractitionerRequestorPendingResponseExample\"> </a><a name=\"PractitionerRequestorPendingResponseExample-en-US\"> </a><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}\">Professional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-SubscriberExample.html\">JOE SMITH Male, DoB Unknown ( Member Number)</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole</a></p><p><b>request</b>: <a href=\"Claim-ReferralAuthorizationExample.html\">Claim: extension = Urgent; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>AdministrationReferenceNumber</b>: PEND0001</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td></tr></table></blockquote></div>"
},
"identifier" : [
{
"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" : "2005-05-02T11:02:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"requestor" : {
🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
},
"request" : {
🔗 "reference" : "Claim/ReferralAuthorizationExample"
},
"outcome" : "complete",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
"valueString" : "PEND0001"
}
],
"itemSequence" : 1,
"adjudication" : [
{
"extension" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/306",
"code" : "A4",
"display" : "Pending"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
}
],
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted"
}
]
}
}
]
}
]
}
},
{
"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\"><a name=\"Organization_UMOExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization UMOExample</b></p><a name=\"UMOExample\"> </a><a name=\"hcUMOExample\"> </a><a name=\"UMOExample-en-US\"> </a><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/5.3.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 X3}\">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\"><a name=\"Organization_InsurerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization InsurerExample</b></p><a name=\"InsurerExample\"> </a><a name=\"hcInsurerExample\"> </a><a name=\"InsurerExample-en-US\"> </a><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/5.3.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 PR}\">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1234567893"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "PR"
}
]
}
],
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"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" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_SubscriberExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient SubscriberExample</b></p><a name=\"SubscriberExample\"> </a><a name=\"hcSubscriberExample\"> </a><a name=\"SubscriberExample-en-US\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">JOE SMITH Male, DoB Unknown ( Member Number)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"A patient's military status.\"><a href=\"StructureDefinition-extension-militaryStatus.html\"/></td><td colspan=\"3\"><span title=\"Codes:{https://codesystem.x12.org/005010/584 RU}\">RU</span></td></tr></table></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" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "MB"
}
]
},
"system" : "http://example.org/MIN",
"value" : "12345678901"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
],
"gender" : "male"
}
},
{
"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\"><a name=\"Practitioner_ReferralPractitionerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner ReferralPractitionerExample</b></p><a name=\"ReferralPractitionerExample\"> </a><a name=\"hcReferralPractitionerExample\"> </a><a name=\"ReferralPractitionerExample-en-US\"> </a><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/5.3.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/1234567893</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" : "1234567893"
}
],
"name" : [
{
"family" : "WATSON",
"given" : [
"SUSAN"
]
}
],
"telecom" : [
{
"system" : "phone",
"value" : "4029993456"
}
]
}
}
]
}
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.1.0 based on FHIR 4.0.1. Generated 2024-12-20
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