Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1 United States of America flag

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

: PAS Claim Inquiry Example - XML Representation

Page standards status: Informative

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<Claim xmlns="http://hl7.org/fhir">
  <id value="PASClaimInquiryExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim PASClaimInquiryExample</b></p><a name="PASClaimInquiryExample"> </a><a name="hcPASClaimInquiryExample"> </a><a name="PASClaimInquiryExample-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>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>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}">G0154</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>CertificationIssueDate</b>: 2019-07-01</p><p><b>CertificationEffectiveDate</b>: 2019-07-01</p><p><b>CertificationExpirationDate</b>: 2019-07-31</p><p><b>ReviewActionCode</b>: <span title="Codes:{https://codesystem.x12.org/005010/306 A1}">Certified in total</span></p><p><b>ProductOrServiceCodeEnd</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4190}">B4190</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}">B4184</span></p></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="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"/>
    <productOrService>
      <coding>
        <system
                value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
        <code value="G0154"/>
      </coding>
    </productOrService>
  </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-itemCertificationIssueDate">
      <valueDate value="2019-07-01"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate">
      <valueDate value="2019-07-01"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate">
      <valueDate value="2019-07-31"/>
    </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
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
          <code value="B4190"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <sequence value="2"/>
    <productOrService>
      <coding>
        <system
                value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
        <code value="B4184"/>
      </coding>
    </productOrService>
  </item>
</Claim>