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 - XML Representation
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<ClaimResponse xmlns="http://hl7.org/fhir">
<id value="ReferralAuthorizationResponseExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
</meta>
<text>
<status value="extensions"/>
<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: 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> " 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>
</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="2005-05-02T11:02:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<requestor>🔗
<reference value="Organization/UMOExample"/>
</requestor>
<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>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate">
<valueDate value="2005-05-02"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod">
<valuePeriod>
<start value="2005-05-02"/>
<end value="2005-06-02"/>
</valuePeriod>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider">
<extension url="provider">
<valueReference>🔗
<reference value="Practitioner/ReferralPractitionerExample"/>
</valueReference>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail">
<extension url="productOrServiceCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="unitPrice">
<valueMoney>
<value value="100"/>
<currency value="USD"/>
</valueMoney>
</extension>
<extension url="quantity">
<valueQuantity>
<value value="1"/>
</valueQuantity>
</extension>
</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>
</ClaimResponse>
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