{ "resourceType" : "Bundle", "id" : "RejectionResponseBundleExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"] }, "language" : "en", "identifier" : { "system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER", "value" : "A12345" }, "type" : "collection", "timestamp" : "2005-05-02T11:02:00+05:00", "entry" : [{ "fullUrl" : "http://example.org/fhir/ClaimResponse/RejectionResponseExample", "resource" : { "resourceType" : "ClaimResponse", "id" : "RejectionResponseExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: ClaimResponse RejectionResponseExample

Profile: PAS Claim Response

Claim Response Reviewer

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: 2005-05-02 11:02:00+0500

insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY

requestor: Organization DR. JOE SMITH CORPORATION

request: Claim: extension = Urgent,; identifier = urn:trnorg:9012345678#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal

outcome: Complete

item

itemSequence: 1

Adjudications

-ExtensionCategory
*Submitted Amount
" }, "extension" : [{ "extension" : [{ "url" : "wasHumanReviewedFlag", "valueBoolean" : true }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer" }], "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" : "Organization/UMOExample" }, "request" : { "reference" : "Claim/ReferralAuthorizationExample" }, "outcome" : "complete", "item" : [{ "itemSequence" : 1, "adjudication" : [{ "extension" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/306", "code" : "A3", "display" : "Not Certified" }] } }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction" }], "category" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] } }] }] } }, { "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/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" } }, { "fullUrl" : "http://example.org/fhir/Claim/ReferralAuthorizationExample", "resource" : { "resourceType" : "Claim", "id" : "ReferralAuthorizationExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim ReferralAuthorizationExample

Profile: PAS Claim

Level of Service Code: Urgent

Transmission Identifiers

identifier: urn:trnorg:9012345678/111099

status: Active

type: Professional

use: Preauthorization

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

created: 2005-05-02 11:01:00+0500

insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY

provider: Organization DR. JOE SMITH CORPORATION

priority: Normal

CareTeams

-ExtensionSequenceProvider
*1PractitionerRole: telecom = ph: 4029993456

SupportingInfos

-ExtensionSequenceCategoryValue[x]
*1Additional InformationDocumentReference: status = current; type = Physician procedure note; category = Clinical Note

Diagnoses

-ExtensionSequenceDiagnosis[x]
*1Chronic pain syndrome

Insurances

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

item

Service Item Request Type: Specialty Care Review

Certification Type: Initial

Item Trace Number: http://example.org/ITEM_TRACE_NUMBER/1122334

Authorization Number: 1122445

Administration Reference Number: 9988311

Requested Service: ServiceRequest Consultation

EPSDT Indicator: false

Nursing Home Residential Status: Newly Admitted

Nursing Home Level of Care: Intermediate Care Facility (ICF)

Revenue Unit Rate Limit: 100

sequence: 1

careTeamSequence: 1

diagnosisSequence: 1

category: Consultation

productOrService: Consultation

location: Office

" }, "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" }] } }, { "extension" : [{ "url" : "applicationSenderCode", "valueString" : "PROVIDERAPP" }, { "url" : "applicationReceiverCode", "valueString" : "PAYERAPP" }, { "url" : "interchangeSenderID", "valueString" : "PROVIDERID" }, { "url" : "interchangeReceiverID", "valueString" : "PAYERID" }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers" }], "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" : "urn:trnorg:9012345678", "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" } }], "supportingInfo" : [{ "extension" : [{ "extension" : [{ "url" : "reportTypeCode", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/755", "code" : "PY", "display" : "Physician's Report" }] } }, { "url" : "transmissionMethod", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/756", "code" : "EL", "display" : "Electronically Only" }] } }, { "url" : "controlNumber", "valueString" : "111222" }, { "url" : "description", "valueString" : "A procedure note included to provide details of what has been tried before the referral." }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation" }], "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes", "code" : "additionalInformation" }] }, "valueReference" : { "reference" : "DocumentReference/DocumentReferenceExample" } }], "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" }] } }] } }] }