{ "resourceType" : "Claim", "id" : "HomecareAuthorizationUpdateExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update"] }, "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim HomecareAuthorizationUpdateExample

Language: en

Profile: PAS Claim Update

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

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

Relateds

-ClaimRelationship
*Claim: extension = ; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2019-07-20 11:01:00+0500; priority = NormalPrior Claim

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: Cancel

Information Change Mode: changed

Information Cancelled Flag: true

sequence: 2

category: Home Health Care

productOrService: B4184

location: Office

item

Service Item Request Type: Health Services Review

Certification Type: Initial

Information Change Mode: added

sequence: 3

category: Home Health Care

productOrService: Pn soln nos 10 grams lipids

location: Office

" }, "identifier" : [{ "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER", "value" : "111099-UPDATE", "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" }] }, "related" : [{ "claim" : { "reference" : "Claim/HomecareAuthorizationExample" }, "relationship" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship", "code" : "prior" }] } }], "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" : "3", "display" : "Cancel" }] } }, { "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged", "valueCode" : "changed" }], "modifierExtension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled", "valueBoolean" : true }], "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" }] } }, { "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" }] } }, { "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged", "valueCode" : "added" }], "sequence" : 3, "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" : "B4185" }] }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "11" }] } }] }