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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: PAS Claim Inquiry ResponseExample - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "PASClaimInquiryResponseExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClaimResponse</b><a name=\"PASClaimInquiryResponseExample\"> </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;PASClaimInquiryResponseExample&quot; </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claiminquiryresponse.html\">PAS Claim Inquiry 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>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization/InsurerExample</a> &quot;MARYLAND CAPITAL INSURANCE COMPANY&quot;</p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</span></td></tr></table></blockquote><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></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" : "2019-07-20T11:01:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/InsurerExample"
  },
  "outcome" : "complete",
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
          "valuePeriod" : {
            "start" : "2005-05-02",
            "end" : "2005-06-02"
          }
        }
      ],
      "itemSequence" : 1,
      "adjudication" : [
        {
          "extension" : [
            {
              "extension" : [
                {
                  "url" : "number",
                  "valueString" : "AUTH0001"
                },
                {
                  "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "https://codesystem.x12.org/005010/306",
                        "code" : "A1",
                        "display" : "Certified in total"
                      }
                    ]
                  }
                }
              ],
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          }
        }
      ]
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        🔗 "reference" : "Coverage/InsuranceExample"
      }
    }
  ]
}