Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="HomecareAuthorizationDifferentialBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"/>
</meta>
<identifier>
<system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
<value value="A12345"/>
</identifier>
<type value="collection"/>
<timestamp value="2005-05-02T11:01:00+05:00"/>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/HomecareAuthorizationDifferentialExample"/>
<resource>
<Claim>
<id value="HomecareAuthorizationDifferentialExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update"/>
<security>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ObservationValue"/>
<code value="SUBSETTED"/>
</security>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_HomecareAuthorizationDifferentialExample"> </a><p class="res-header-id"><b>Generated Narrative: Claim HomecareAuthorizationDifferentialExample</b></p><a name="HomecareAuthorizationDifferentialExample"> </a><a name="hcHomecareAuthorizationDifferentialExample"> </a><a name="HomecareAuthorizationDifferentialExample-en-US"> </a><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099-UPDATE-DIFF</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>provider</b>: <a href="Organization-UMOExample.html">Organization DR. JOE SMITH CORPORATION</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>Relateds</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Claim</b></td><td><b>Relationship</b></td></tr><tr><td style="display: none">*</td><td><a href="Claim-HomecareAuthorizationExample.html">Claim: extension = ; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2019-07-20 11:01:00+0500; priority = Normal</a></td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship prior}">Prior Claim</span></td></tr></table><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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>InfoCancelledFlag</b>: true</p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 42}">Home Health Care</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}">B4184</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>InfoChanged</b>: added</p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 42}">Home Health Care</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4185}">B4185</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></p></blockquote></div>
</text>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="111099-UPDATE-DIFF"/>
<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>
<provider>🔗
<reference value="Organization/UMOExample"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<related>
<claim>🔗
<reference value="Claim/HomecareAuthorizationExample"/>
</claim>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"/>
<code value="prior"/>
</coding>
</relationship>
</related>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="HS"/>
<display value="Health Services Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<modifierExtension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled">
<valueBoolean value="true"/>
</modifierExtension>
<sequence value="2"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="42"/>
<display value="Home Health Care"/>
</coding>
</category>
<productOrService>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="B4184"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="HS"/>
<display value="Health Services Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged">
<valueCode value="added"/>
</extension>
<sequence value="3"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="42"/>
<display value="Home Health Care"/>
</coding>
</category>
<productOrService>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="B4185"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/UMOExample"/>
<resource>
<Organization>
<id value="UMOExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_UMOExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization UMOExample</b></p><a name="UMOExample"> </a><a name="hcUMOExample"> </a><a name="UMOExample-en-US"> </a><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.3.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 X3}">X3</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="8189991234"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="X3"/>
</coding>
</type>
<name value="DR. JOE SMITH CORPORATION"/>
<address>
<line value="111 1ST STREET"/>
<city value="SAN DIEGO"/>
<state value="CA"/>
<postalCode value="92101"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/InsurerExample"/>
<resource>
<Organization>
<id value="InsurerExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_InsurerExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization InsurerExample</b></p><a name="InsurerExample"> </a><a name="hcInsurerExample"> </a><a name="InsurerExample-en-US"> </a><p><b>identifier</b>: <a href="http://terminology.hl7.org/5.3.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 PR}">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234567893"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="PR"/>
</coding>
</type>
<name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/InsuranceExample"/>
<resource>
<Coverage>
<id value="InsuranceExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Coverage_InsuranceExample"> </a><p class="res-header-id"><b>Generated Narrative: Coverage InsuranceExample</b></p><a name="InsuranceExample"> </a><a name="hcInsuranceExample"> </a><a name="InsuranceExample-en-US"> </a><p><b>status</b>: Active</p><p><b>subscriberId</b>: 1122334455</p><p><b>beneficiary</b>: <a href="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( Member Number)</a></p><p><b>relationship</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}, {https://codesystem.x12.org/005010/1069 18}">Self</span></p><p><b>payor</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p></div>
</text>
<status value="active"/>
<subscriberId value="1122334455"/>
<beneficiary>🔗
<reference value="Patient/SubscriberExample"/>
</beneficiary>
<relationship>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/subscriber-relationship"/>
<code value="self"/>
</coding>
<coding>
<system value="https://codesystem.x12.org/005010/1069"/>
<code value="18"/>
</coding>
</relationship>
<payor>🔗
<reference value="Organization/InsurerExample"/>
</payor>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/SubscriberExample"/>
<resource>
<Patient>
<id value="SubscriberExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_SubscriberExample"> </a><p class="res-header-id"><b>Generated Narrative: Patient SubscriberExample</b></p><a name="SubscriberExample"> </a><a name="hcSubscriberExample"> </a><a name="SubscriberExample-en-US"> </a><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">JOE SMITH Male, DoB Unknown ( Member Number)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="A patient's military status."><a href="StructureDefinition-extension-militaryStatus.html"/></td><td colspan="3"><span title="Codes:{https://codesystem.x12.org/005010/584 RU}">RU</span></td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/584"/>
<code value="RU"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MB"/>
</coding>
</type>
<system value="http://example.org/MIN"/>
<value value="12345678901"/>
</identifier>
<name>
<family value="SMITH"/>
<given value="JOE"/>
</name>
<gender value="male"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/HomecareAuthorizationExample"/>
<resource>
<Claim>
<id value="HomecareAuthorizationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_HomecareAuthorizationExample"> </a><p class="res-header-id"><b>Generated Narrative: Claim HomecareAuthorizationExample</b></p><a name="HomecareAuthorizationExample"> </a><a name="hcHomecareAuthorizationExample"> </a><a name="HomecareAuthorizationExample-en-US"> </a><blockquote><p><b>HomeHealthCareInformation</b></p><ul><li>prognosis: <span title="Codes:{https://codesystem.x12.org/005010/923 1}">1</span></li><li>date: 2005-05-02</li></ul></blockquote><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>provider</b>: <a href="Organization-UMOExample.html">Organization DR. JOE SMITH CORPORATION</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 42}">Home Health Care</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}">G0154</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 42}">Home Health Care</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}">B4184</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></p></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation">
<extension url="prognosis">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/923"/>
<code value="1"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="date">
<valueDate value="2005-05-02"/>
</extension>
</extension>
<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>
<provider>🔗
<reference value="Organization/UMOExample"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="HS"/>
<display value="Health Services Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="1"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="42"/>
<display value="Home Health Care"/>
</coding>
</category>
<productOrService>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="G0154"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="HS"/>
<display value="Health Services Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<sequence value="2"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="42"/>
<display value="Home Health Care"/>
</coding>
</category>
<productOrService>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="B4184"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
</resource>
</entry>
</Bundle>
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.1.0 based on FHIR 4.0.1. Generated 2024-12-20
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