This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0: 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 |
<ClaimResponse xmlns="http://hl7.org/fhir">
<id value="PASClaimInquiryResponseExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse PASClaimInquiryResponseExample</b></p><a name="PASClaimInquiryResponseExample"> </a><a name="hcPASClaimInquiryResponseExample"> </a><a name="PASClaimInquiryResponseExample-en-US"> </a><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( Member Number)</a></p><p><b>created</b>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>request</b>: <a href="Claim-ReferralAuthorizationExample.html">Claim: extension = Urgent; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --> 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><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</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: status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table></div>
</text>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="111099"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="9012345678"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>🔗
<reference value="Patient/SubscriberExample"/>
</patient>
<created value="2019-07-20T11:01:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<request>🔗
<reference value="Claim/ReferralAuthorizationExample"/>
</request>
<outcome value="complete"/>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate">
<valuePeriod>
<start value="2005-05-02"/>
<end value="2005-06-02"/>
</valuePeriod>
</extension>
<itemSequence value="1"/>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
<extension url="number">
<valueString value="AUTH0001"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/306"/>
<code value="A1"/>
<display value="Certified in total"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<category>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
</adjudication>
</item>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
</ClaimResponse>