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

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: Medical Services Authorization Example - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "MedicalServicesAuthorizationExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Claim MedicalServicesAuthorizationExample</b></p><a name=\"MedicalServicesAuthorizationExample\"> </a><a name=\"hcMedicalServicesAuthorizationExample\"> </a><a name=\"MedicalServicesAuthorizationExample-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>: 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>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 IN}\">Initial Medical Services Reservation</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>AuthorizationNumber</b>: 1122344</p><p><b>AdministrationReferenceNumber</b>: 33441122</p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 1}\">Medical Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets 99212}\">Established Office Visit</span></p><p><b>serviced</b>: 2005-05-10</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>"
  },
  "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" : "2005-05-02T11:01:00+05:00",
  "insurer" : {
    🔗 "reference" : "Organization/InsurerExample"
  },
  "provider" : {
    🔗 "reference" : "Organization/UMOExample"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "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" : "IN",
                "display" : "Initial Medical Services Reservation"
              }
            ]
          }
        },
        {
          "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-authorizationNumber",
          "valueString" : "1122344"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
          "valueString" : "33441122"
        }
      ],
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "https://codesystem.x12.org/005010/1365",
            "code" : "1",
            "display" : "Medical Care"
          }
        ]
      },
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "99212",
            "display" : "Established Office Visit"
          }
        ]
      },
      "servicedDate" : "2005-05-10",
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code" : "11"
          }
        ]
      }
    }
  ]
}