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 - XML Representation

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<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><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: 111099</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>
  </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>
  <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>