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 Claim: PAS Claim Inquiry Example

Page standards status: Informative

Generated Narrative: Claim

Resource Claim "PASClaimInquiryExample"

Profile: PAS Claim Inquiry

identifier: id: 111099

status: active

type: Professional (Claim Type Codes#professional)

use: preauthorization

patient: Patient/SubscriberExample " SMITH"

created: 2019-07-20 11:01:00+0500

insurer: Organization/InsurerExample "MARYLAND CAPITAL INSURANCE COMPANY"

provider: Organization/UMOExample "DR. JOE SMITH CORPORATION"

priority: Normal (Process Priority Codes#normal)

Insurances

-SequenceFocalCoverage
*1trueCoverage/InsuranceExample

item

ServiceItemRequestType: Health Services Review (1525#HS)

CertificationType: Initial (1322#I)

sequence: 1

productOrService: G0154 (HCPCSReleaseCodeSets#G0154)

item

ServiceItemRequestType: Health Services Review (1525#HS)

CertificationType: Initial (1322#I)

CertificationIssueDate: 2019-07-01

CertificationEffectiveDate: 2019-07-01

CertificationExpirationDate: 2019-07-31

ReviewActionCode: Certified in total (306#A1)

ProductOrServiceCodeEnd: B4190 (HCPCSReleaseCodeSets#B4190)

sequence: 2

productOrService: B4184 (HCPCSReleaseCodeSets#B4184)