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
| Page standards status: Informative |
{
"resourceType" : "ClaimResponse",
"id" : "PractitionerRequestorAdditionalContentResponseExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorAdditionalContentResponseExample</b></p><a name=\"PractitionerRequestorAdditionalContentResponseExample\"> </a><a name=\"hcPractitionerRequestorAdditionalContentResponseExample\"> </a><a name=\"PractitionerRequestorAdditionalContentResponseExample-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 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole</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>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --> 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><ul><li>provider: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner SUSAN WATSON </a></li></ul></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><ul><li>productOrServiceCode: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</span></li><li>unitPrice: <span title=\"US Dollar\">$100.00</span> (USD)</li><li>quantity: 1</li></ul></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><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></td></tr></table></blockquote><blockquote><p><b>addItem</b></p><p><b>RevenueCode</b>: <span title=\"Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0202}\">0202</span></p><p><b>itemSequence</b>: 2</p><p><b>provider</b>: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner SUSAN WATSON </a></p><p><b>productOrService</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">3</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>100</td><td>United States dollar</td></tr></table><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></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" : "2005-05-02T11:02:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"requestor" : {
🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
},
"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"
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
"valueDate" : "2005-05-02"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
"valuePeriod" : {
"start" : "2005-05-02",
"end" : "2005-06-02"
}
},
{
"extension" : [
{
"url" : "provider",
"valueReference" : {
🔗 "reference" : "Practitioner/ReferralPractitionerExample"
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider"
},
{
"extension" : [
{
"url" : "productOrServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3",
"display" : "Consultation"
}
]
}
},
{
"url" : "unitPrice",
"valueMoney" : {
"value" : 100,
"currency" : "USD"
}
},
{
"url" : "quantity",
"valueQuantity" : {
"value" : 1
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
}
],
"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"
}
]
}
}
]
}
],
"addItem" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.nubc.org/CodeSystem/RevenueCodes",
"code" : "0202"
}
]
}
}
],
"itemSequence" : [
2
],
"provider" : [
{
🔗 "extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "P3"
}
]
}
}
],
"reference" : "Practitioner/ReferralPractitionerExample"
}
],
"productOrService" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1365",
"code" : "3"
}
]
},
"quantity" : {
"value" : 1
},
"unitPrice" : {
"value" : 100,
"currency" : "USD"
},
"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"
}
]
}
}
]
}
]
}
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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