{
  "resourceType" : "Claim",
  "id" : "PASClaimInquiryExample",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"]
  },
  "language" : "en",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: Claim PASClaimInquiryExample</b></p><a name=\"PASClaimInquiryExample\"> </a><a name=\"hcPASClaimInquiryExample\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim-inquiry.html\">PAS Claim Inquiry</a></p></div><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 ( http://example.org/MIN#12345678901)</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: identifier = Member Number; status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Item Request Type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>Certification Type</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}\">health or hospice setting, each 15 minutes</span></p></blockquote><blockquote><p><b>item</b></p><p><b>Service Item Request Type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>Certification Type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>Certification Issue Date</b>: 2019-07-01</p><p><b>Certification Effective Date</b>: 2019-07-01</p><p><b>Certification Expiration Date</b>: 2019-07-31</p><p><b>Review Action Code</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/306 A1}\">Certified in total</span></p><p><b>Product or Service Code End</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>"
  },
  "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,
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
        "code" : "G0154"
      }]
    }
  },
  {
    "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-itemCertificationIssueDate",
      "valueDate" : "2019-07-01"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate",
      "valueDate" : "2019-07-01"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate",
      "valueDate" : "2019-07-31"
    },
    {
      "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-productOrServiceCodeEnd",
      "valueCodeableConcept" : {
        "coding" : [{
          "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
          "code" : "B4190"
        }]
      }
    }],
    "sequence" : 2,
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
        "code" : "B4184"
      }]
    }
  }]
}