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
: Referral Authorization Response Example - JSON Representation
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{
"resourceType" : "ClaimResponse",
"id" : "ReferralAuthorizationResponseExample",
"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=\"ReferralAuthorizationResponseExample\"> </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 "ReferralAuthorizationResponseExample" </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> " SMITH"</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> "MARYLAND CAPITAL INSURANCE COMPANY"</p><p><b>requestor</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> "DR. JOE SMITH CORPORATION"</p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --> 2005-06-02</p><p><b>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --> 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><blockquote><p><b>url</b></p><code>provider</code></blockquote><p><b>value</b>: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner/ReferralPractitionerExample</a> " WATSON"</p></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><blockquote><p><b>url</b></p><code>productOrServiceCode</code></blockquote><p><b>value</b>: Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1365#3)</span></p><blockquote><p><b>url</b></p><code>unitPrice</code></blockquote><p><b>value</b>: <span title=\"US Dollar\">US$100.00</span> (USD)</p><blockquote><p><b>url</b></p><code>quantity</code></blockquote><p><b>value</b>: 1</p></blockquote><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></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" : "complete",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
"valueDate" : "2005-05-02"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
},
{
"extension" : [
{
"url" : "provider",
"valueReference" : {
🔗 "reference" : "Practitioner/ReferralPractitionerExample"
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider"
},
{
"extension" : [
{
"url" : "productOrServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
}
},
{
"url" : "unitPrice",
"valueMoney" : {
"value" : 100,
"currency" : "USD"
}
},
{
"url" : "quantity",
"valueQuantity" : {
"value" : 1
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
}
],
"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"
}
]
}
}
]
}
]
}
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