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: Surgical Request Authorization Example

Page standards status: Informative

Generated Narrative: Claim

Resource Claim "SurgicalAuthorizationRequestExample"

Profile: PAS Claim

LevelOfServiceCode: Elective (1338#E)

Extension Definition for Claim.encounter for Version 5.0: Encounter/SurgicalEncounterExample

ConditionCode

url

category

value: 07 (1136#07)

url

indicator

value: true

url

code

value: 09 (1321#09)

identifier: id: 16139462398

status: active

type: Institutional (Claim Type Codes#institutional)

use: preauthorization

patient: Patient/SubscriberExample " SMITH"

created: 2020-06-24 07:34:00+0500

insurer: Organization/InsurerExample "MARYLAND CAPITAL INSURANCE COMPANY"

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

priority: Normal (Process Priority Codes#normal)

CareTeams

-ExtensionSequenceProvider
*1PractitionerRole/SurgicalPractitionerRoleExample

SupportingInfos

-SequenceCategoryTiming[x]
*1Admission Dates (PAS Temporary Codes#admissionDates)2020-07-02 --> 2020-07-09

Diagnoses

-ExtensionSequenceDiagnosis[x]
*1C18.9 (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#C18.9)

Insurances

-SequenceFocalCoverage
*1trueCoverage/InsuranceExample

Items

-ExtensionSequenceCareTeamSequenceDiagnosisSequenceCategoryProductOrServiceLocation[x]
*, , , , 111Surgical (1365#2)Under Venous Grafting Only for Coronary Artery Bypass (HCPCSReleaseCodeSets#33510)21 (CMS Place of Service Codes (POS)#21)