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
<Bundle xmlns="http://hl7.org/fhir">
<id value="ReferralPendingAuthorizationResponseBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"/>
</meta>
<type value="collection"/>
<timestamp value="2005-05-02T11:02:00+05:00"/>
<entry>
<fullUrl
value="http://example.org/fhir/ClaimResponse/PractitionerRequestorPendingResponseExample"/>
<resource>
<ClaimResponse>
<id value="PractitionerRequestorPendingResponseExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
</meta>
<text>
<status value="extensions"/>
<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>
</text>
<identifier>
<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="2005-05-02T11:02:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<requestor>🔗
<reference
value="PractitionerRole/ReferralPractitionerRoleExample"/>
</requestor>
<request>🔗
<reference value="Claim/ReferralAuthorizationExample"/>
</request>
<outcome value="complete"/>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber">
<valueString value="PEND0001"/>
</extension>
<itemSequence value="1"/>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/306"/>
<code value="A4"/>
<display value="Pending"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
</adjudication>
</item>
</ClaimResponse>
</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"><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>
</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"><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>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234567893"/>
</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/Patient/SubscriberExample"/>
<resource>
<Patient>
<id value="SubscriberExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
</meta>
<text>
<status value="generated"/>
<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>
</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>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MB"/>
</coding>
</type>
<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/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"><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>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234567893"/>
</identifier>
<name>
<family value="WATSON"/>
<given value="SUSAN"/>
</name>
<telecom>
<system value="phone"/>
<value value="4029993456"/>
</telecom>
</Practitioner>
</resource>
</entry>
</Bundle>
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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