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
: Homecare Authorization Differential Update Example - JSON Representation
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{
"resourceType" : "Claim",
"id" : "HomecareAuthorizationDifferentialExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update"
],
"security" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationValue",
"code" : "SUBSETTED"
}
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"HomecareAuthorizationDifferentialExample\"> </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 "HomecareAuthorizationDifferentialExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim-update.html\">PAS Claim Update</a></p><p style=\"margin-bottom: 0px\">Security Labels: <span title=\"{http://terminology.hl7.org/CodeSystem/v3-ObservationValue http://terminology.hl7.org/CodeSystem/v3-ObservationValue}\">http://terminology.hl7.org/CodeSystem/v3-ObservationValue</span></p></div><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.html\">Patient/SubscriberExample</a> " SMITH"</p><p><b>created</b>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization/InsurerExample</a> "MARYLAND CAPITAL INSURANCE COMPANY"</p><p><b>provider</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> "DR. JOE SMITH CORPORATION"</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>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.html\">Coverage/InsuranceExample</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1322#I)</span></p><blockquote><p><b>modifierExtension[http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled]</b></p></blockquote><p><b>sequence</b>: 2</p><p><b>category</b>: Home Health Care <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#42)</span></p><p><b>productOrService</b>: B4184 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#B4184)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>InfoChanged</b>: added</p><p><b>ServiceItemRequestType</b>: Health Services Review <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1322#I)</span></p><p><b>sequence</b>: 3</p><p><b>category</b>: Home Health Care <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#42)</span></p><p><b>productOrService</b>: B4185 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#B4185)</span></p></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" : "2019-07-20T11:01:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"provider" : {
🔗 "reference" : "Organization/UMOExample"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/InsuranceExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "HS",
"display" : "Health Services 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"
}
]
}
}
],
"modifierExtension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled",
"valueBoolean" : true
}
],
"sequence" : 2,
"category" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "42",
"display" : "Home Health Care"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "B4184"
}
]
}
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged",
"valueCode" : "added"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "HS",
"display" : "Health Services 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"
}
]
}
}
],
"sequence" : 3,
"category" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "42",
"display" : "Home Health Care"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "B4185"
}
]
}
}
]
}
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