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
{
"resourceType" : "Bundle",
"id" : "PASClaimInquiryResponseBundleExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"
]
},
"identifier" : {
"system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value" : "5269367"
},
"type" : "collection",
"timestamp" : "2005-05-02T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample",
"resource" : {
"resourceType" : "ClaimResponse",
"id" : "PASClaimInquiryResponseExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_PASClaimInquiryResponseExample\"> </a><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>"
},
"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" : "2019-07-20T11:01:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"request" : {
🔗 "reference" : "Claim/ReferralAuthorizationExample"
},
"outcome" : "complete",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
}
],
"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"
}
]
}
}
]
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/InsuranceExample"
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/UMOExample",
"resource" : {
"resourceType" : "Organization",
"id" : "UMOExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "8189991234"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "X3"
}
]
}
],
"name" : "DR. JOE SMITH CORPORATION",
"address" : [
{
"line" : [
"111 1ST STREET"
],
"city" : "SAN DIEGO",
"state" : "CA",
"postalCode" : "92101",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/InsurerExample",
"resource" : {
"resourceType" : "Organization",
"id" : "InsurerExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "1234567893"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "PR"
}
]
}
],
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/InsuranceExample",
"resource" : {
"resourceType" : "Coverage",
"id" : "InsuranceExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"status" : "active",
"subscriberId" : "1122334455",
"beneficiary" : {
🔗 "reference" : "Patient/SubscriberExample"
},
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code" : "self"
},
{
"system" : "https://codesystem.x12.org/005010/1069",
"code" : "18"
}
]
},
"payor" : [
{
🔗 "reference" : "Organization/InsurerExample"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/SubscriberExample",
"resource" : {
"resourceType" : "Patient",
"id" : "SubscriberExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"
]
},
"text" : {
"status" : "generated",
"div" : "<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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/584",
"code" : "RU"
}
]
}
}
],
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "MB"
}
]
},
"system" : "http://example.org/MIN",
"value" : "12345678901"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
],
"gender" : "male"
}
},
{
"fullUrl" : "http://example.org/fhir/Claim/ReferralAuthorizationExample",
"resource" : {
"resourceType" : "Claim",
"id" : "ReferralAuthorizationExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_ReferralAuthorizationExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim ReferralAuthorizationExample</b></p><a name=\"ReferralAuthorizationExample\"> </a><a name=\"hcReferralAuthorizationExample\"> </a><a name=\"ReferralAuthorizationExample-en-US\"> </a><p><b>LevelOfServiceCode</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1338 U}\">Urgent</span></p><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>: 2005-05-02 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>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td><a href=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole</a></td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm G89.4}\">Chronic pain syndrome</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 SC}\">Specialty Care Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>ItemTraceNumber</b>: <code>http://example.org/ITEM_TRACE_NUMBER</code>/1122334</p><p><b>AuthorizationNumber</b>: 1122445</p><p><b>AdministrationReferenceNumber</b>: 9988311</p><p><b>RequestedService</b>: <a href=\"ServiceRequest-ReferralRequestExample.html\">ServiceRequest Consultation</a></p><p><b>EPSDTIndicator</b>: false</p><p><b>NursingHomeResidentialStatus</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1345 2}\">Newly Admitted</span></p><p><b>NursingHomeLevelOfCare</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1337 2}\">Intermediate Care Facility (ICF)</span></p><p><b>RevenueUnitRateLimit</b>: 100</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</span></p><p><b>productOrService</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</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>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1338",
"code" : "U",
"display" : "Urgent"
}
]
}
}
],
"identifier" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.usps.com/",
"code" : "MA"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment",
"valueString" : "223412"
}
],
"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" : "2005-05-02T11:01:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"provider" : {
🔗 "reference" : "Organization/UMOExample"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"careTeam" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
"valueBoolean" : true
}
],
"sequence" : 1,
"provider" : {
🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
}
}
],
"diagnosis" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
"valueDate" : "2021-05-10"
}
],
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G89.4"
}
]
}
}
],
"insurance" : [
{
"sequence" : 1,
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/InsuranceExample"
}
}
],
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "SC",
"display" : "Specialty Care Review"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1322",
"code" : "I",
"display" : "Initial"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
"valueIdentifier" : {
"system" : "http://example.org/ITEM_TRACE_NUMBER",
"value" : "1122334"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
"valueString" : "1122445"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
"valueString" : "9988311"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference" : {
🔗 "reference" : "ServiceRequest/ReferralRequestExample"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator",
"valueBoolean" : false
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1345",
"code" : "2",
"display" : "Newly Admitted"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1337",
"code" : "2",
"display" : "Intermediate Care Facility (ICF)"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit",
"valueDecimal" : 100
}
],
"sequence" : 1,
"careTeamSequence" : [
1
],
"diagnosisSequence" : [
1
],
"category" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
},
"locationCodeableConcept" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code" : "11"
}
]
}
}
]
}
}
]
}
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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