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

: Surgical Request Authorization Example - TTL Representation

Page standards status: Informative

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Claim ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "SurgicalAuthorizationRequestExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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 &quot;SurgicalAuthorizationRequestExample&quot; </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: 16139462398</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> &quot; SMITH&quot;</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> &quot;MARYLAND CAPITAL INSURANCE COMPANY&quot;</p><p><b>provider</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> &quot;DR. JOE SMITH CORPORATION&quot;</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 --&gt; 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>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1338"^^xsd:anyURI ] ;
fhir:code [ fhir:v "E" ] ;
fhir:display [ fhir:v "Elective" ]       ] )     ]
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Encounter/SurgicalEncounterExample" ]     ]
  ] [
    ( fhir:extension [
fhir:url [ fhir:v "category"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1136"^^xsd:anyURI ] ;
fhir:code [ fhir:v "07" ]         ] )       ]     ] [
fhir:url [ fhir:v "indicator"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]     ] [
fhir:url [ fhir:v "code"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1321"^^xsd:anyURI ] ;
fhir:code [ fhir:v "09" ]         ] )       ]     ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode"^^xsd:anyURI ]
  ] ) ; # 
  fhir:identifier ( [
fhir:system [ fhir:v "http://example.org/PATIENT_EVENT_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "16139462398" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [ fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ] ;
fhir:value [ fhir:v "3030240928" ]       ]     ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "institutional" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
  ] ; # 
  fhir:created [ fhir:v "2020-06-24T07:34:00+05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:reference [ fhir:v "Organization/InsurerExample" ]
  ] ; # 
  fhir:provider [
fhir:reference [ fhir:v "Organization/UMOExample" ]
  ] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ]     ] )
  ] ; # 
  fhir:careTeam ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"^^xsd:anyURI ] ;
fhir:value [ fhir:v "true"^^xsd:boolean ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:reference [ fhir:v "PractitionerRole/SurgicalPractitionerRoleExample" ]     ]
  ] ) ; # 
  fhir:supportingInfo ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "admissionDates" ]       ] )     ] ;
fhir:timing [
a fhir:Period ;
fhir:start [ fhir:v "2020-07-02"^^xsd:date ] ;
fhir:end [ fhir:v "2020-07-09"^^xsd:date ]     ]
  ] ) ; # 
  fhir:diagnosis ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2020-06-24"^^xsd:date ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "C18.9" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/InsuranceExample" ]     ]
  ] ) ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber"^^xsd:anyURI ] ;
fhir:value [
a fhir:Identifier ;
fhir:system [ fhir:v "http://example.org/ITEM_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "1122334" ]       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "1122445" ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber"^^xsd:anyURI ] ;
fhir:value [ fhir:v "9988311" ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ] ;
fhir:code [ fhir:v "AR" ] ;
fhir:display [ fhir:v "Admission Review" ]         ] )       ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ]         ] )       ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:careTeamSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:diagnosisSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:category [
      ( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ] ;
fhir:display [ fhir:v "Surgical" ]       ] )     ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [ fhir:v "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ;
fhir:code [ fhir:v "33510" ] ;
fhir:display [ fhir:v "Under Venous Grafting Only for Coronary Artery Bypass" ]       ] )     ] ;
fhir:location [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [ fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ] ;
fhir:code [ fhir:v "21" ]       ] )     ]
  ] ) . #