{ "resourceType" : "Bundle", "id" : "HomecareAuthorizationBundleExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"] }, "language" : "en", "identifier" : { "system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER", "value" : "B56789" }, "type" : "collection", "timestamp" : "2005-05-02T14:30:00+05:00", "entry" : [{ "fullUrl" : "http://example.org/fhir/Claim/HomecareAuthorizationExample", "resource" : { "resourceType" : "Claim", "id" : "HomecareAuthorizationExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim HomecareAuthorizationExample

Profile: PAS Claim

Home Health Care Information

identifier: http://example.org/PATIENT_EVENT_TRACE_NUMBER/111099

status: Active

type: Professional

use: Preauthorization

patient: JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)

created: 2019-07-20 11:01:00+0500

insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY

provider: Organization DR. JOE SMITH CORPORATION

priority: Normal

Insurances

-SequenceFocalCoverage
*1trueCoverage: identifier = Member Number; status = active; subscriberId = 1122334455; relationship = Self

item

Service Item Request Type: Health Services Review

Certification Type: Initial

sequence: 1

category: Home Health Care

productOrService: health or hospice setting, each 15 minutes

location: Office

item

Service Item Request Type: Health Services Review

Certification Type: Initial

sequence: 2

category: Home Health Care

productOrService: B4184

location: Office

" }, "extension" : [{ "extension" : [{ "url" : "prognosis", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/923", "code" : "1" }] } }, { "url" : "date", "valueDate" : "2005-05-02" }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation" }], "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" }, "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" : "HS", "display" : "Health Services 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" }] } }], "sequence" : 1, "category" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1365", "code" : "42", "display" : "Home Health Care" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", "code" : "G0154" }] }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "11" }] } }, { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1525", "code" : "HS", "display" : "Health Services 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" }] } }], "sequence" : 2, "category" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1365", "code" : "42", "display" : "Home Health Care" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", "code" : "B4184" }] }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "11" }] } }] } }, { "fullUrl" : "http://example.org/fhir/Organization/UMOExample", "resource" : { "resourceType" : "Organization", "id" : "UMOExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: Organization UMOExample

Profile: PAS Requestor Organization

identifier: United States National Provider Identifier/8189991234

active: true

type: X3

name: DR. JOE SMITH CORPORATION

address: 111 1ST STREET SAN DIEGO CA 92101 US

" }, "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"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: Organization InsurerExample

Profile: PAS Insurer Organization

identifier: United States National Provider Identifier/1234567893

active: true

type: PR

name: MARYLAND CAPITAL INSURANCE COMPANY

" }, "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"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: Coverage InsuranceExample

Profile: PAS Coverage

identifier: Member Number/?ngen-9?

status: Active

subscriberId: 1122334455

beneficiary: JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)

relationship: Self

payor: Organization MARYLAND CAPITAL INSURANCE COMPANY

" }, "identifier" : [{ "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "MB" }] } }], "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"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: Patient SubscriberExample

Profile: PAS Subscriber Patient

JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)

Military StatusRU
" }, "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/584", "code" : "RU" }] } }], "identifier" : [{ "system" : "http://example.org/MIN", "value" : "12345678901" }], "name" : [{ "family" : "SMITH", "given" : ["JOE"] }], "gender" : "male" } }] }