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

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: Error Response Example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "ErrorResponseExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClaimResponse</b><a name=\"ErrorResponseExample\"> </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 ClaimResponse &quot;ErrorResponseExample&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claimresponse.html\">PAS Claim Response</a></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> &quot; SMITH&quot;</p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization/InsurerExample</a> &quot;MARYLAND CAPITAL INSURANCE COMPANY&quot;</p><p><b>requestor</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> &quot;DR. JOE SMITH CORPORATION&quot;</p><p><b>outcome</b>: error</p><blockquote><p><b>error</b></p><p><b>code</b>: 04 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (901#04)</span></p></blockquote><blockquote><p><b>error</b></p><p><b>ErrorElement</b>: 2010A-NM103</p><p><b>ErrorPath</b>: Bundle.entry[1].Organization.name</p><p><b>ErrorFollowupAction</b>: C <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (889#C)</span></p><p><b>code</b>: T4 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (901#T4)</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" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/InsurerExample"
  },
  "requestor" : {
    🔗 "reference" : "Organization/UMOExample"
  },
  "outcome" : "error",
  "error" : [
    {
      "code" : {
        "coding" : [
          {
            "system" : "https://codesystem.x12.org/005010/901",
            "code" : "04"
          }
        ]
      }
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement",
          "valueString" : "2010A-NM103"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath",
          "valueString" : "Bundle.entry[1].Organization.name"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/889",
                "code" : "C"
              }
            ]
          }
        }
      ],
      "code" : {
        "coding" : [
          {
            "system" : "https://codesystem.x12.org/005010/901",
            "code" : "T4"
          }
        ]
      }
    }
  ]
}