Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
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
| Page standards status: Informative |
{
"resourceType" : "Claim",
"id" : "SurgicalAuthorizationRequestExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"SurgicalAuthorizationRequestExample\"> </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 "SurgicalAuthorizationRequestExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim.html\">PAS Claim</a></p></div><p><b>LevelOfServiceCode</b>: Elective <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1338#E)</span></p><p><b>Extension Definition for Claim.encounter for Version 5.0</b>: <a href=\"Encounter-SurgicalEncounterExample.html\">Encounter/SurgicalEncounterExample</a></p><blockquote><p><b>ConditionCode</b></p><blockquote><p><b>url</b></p><code>category</code></blockquote><p><b>value</b>: 07 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1136#07)</span></p><blockquote><p><b>url</b></p><code>indicator</code></blockquote><p><b>value</b>: true</p><blockquote><p><b>url</b></p><a href=\"http://hl7.org/fhir/R4/datatypes.html#code\">code</a></blockquote><p><b>value</b>: 09 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1321#09)</span></p></blockquote><p><b>identifier</b>: id:\u00a016139462398</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <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>#institutional)</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>: 2020-06-24 07:34:00+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>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td><a href=\"PractitionerRole-SurgicalPractitionerRoleExample.html\">PractitionerRole/SurgicalPractitionerRoleExample</a></td></tr></table><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>Admission Dates <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PASTempCodes.html\">PAS Temporary Codes</a>#admissionDates)</span></td><td>2020-07-02 --> 2020-07-09</td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td>C18.9 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#C18.9)</span></td></tr></table><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><h3>Items</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>DiagnosisSequence</b></td><td><b>Category</b></td><td><b>ProductOrService</b></td><td><b>Location[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>, , , , </td><td>1</td><td>1</td><td>1</td><td>Surgical <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#2)</span></td><td>Under Venous Grafting Only for Coronary Artery Bypass <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#33510)</span></td><td>21 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-CMSPlaceofServiceCodes.html\">CMS Place of Service Codes (POS)</a>#21)</span></td></tr></table></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1338",
"code" : "E",
"display" : "Elective"
}
]
}
},
{
"url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter",
"valueReference" : {
🔗 "reference" : "Encounter/SurgicalEncounterExample"
}
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1136",
"code" : "07"
}
]
}
},
{
"url" : "indicator",
"valueBoolean" : true
},
{
"url" : "code",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1321",
"code" : "09"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode"
}
],
"identifier" : [
{
"system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value" : "16139462398",
"assigner" : {
"identifier" : {
"system" : "http://example.org/USER_ASSIGNED",
"value" : "3030240928"
}
}
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
]
},
"use" : "preauthorization",
"patient" : {
🔗 "reference" : "Patient/SubscriberExample"
},
"created" : "2020-06-24T07:34:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"provider" : {
🔗 "reference" : "Organization/UMOExample"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"careTeam" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
"valueBoolean" : true
}
],
"sequence" : 1,
"provider" : {
🔗 "reference" : "PractitionerRole/SurgicalPractitionerRoleExample"
}
}
],
"supportingInfo" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "admissionDates"
}
]
},
"timingPeriod" : {
"start" : "2020-07-02",
"end" : "2020-07-09"
}
}
],
"diagnosis" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
"valueDate" : "2020-06-24"
}
],
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "C18.9"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/InsuranceExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
"valueIdentifier" : {
"system" : "http://example.org/ITEM_TRACE_NUMBER",
"value" : "1122334"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
"valueString" : "1122445"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
"valueString" : "9988311"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "AR",
"display" : "Admission 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" : 1,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"category" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "2",
"display" : "Surgical"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "33510",
"display" : "Under Venous Grafting Only for Coronary Artery Bypass"
}
]
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "21"
}
]
}
}
]
}
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.0.1 based on FHIR 4.0.1. Generated 2023-12-01
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