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

Generated Narrative: Claim SurgicalAuthorizationRequestExample

Language: en

Profile: PAS Claim

Level of Service Code: Elective

R5: Encounters associated with the listed treatments (new): Encounter: extension = Still a patient; status = planned; class = ambulatory (ActCode#AMB); type = 2; period = 2020-07-02 --> 2020-07-09

Condition Code

identifier: http://example.org/PATIENT_EVENT_TRACE_NUMBER/16139462398

status: Active

type: Institutional

use: Preauthorization

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

created: 2020-06-24 07:34:00+0500

insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY

provider: Organization DR. JOE SMITH CORPORATION

priority: Normal

CareTeams

-ExtensionSequenceProvider
*1PractitionerRole: telecom = ph: 4029993456

SupportingInfos

-SequenceCategoryTiming[x]
*1Admission Dates2020-07-02 --> 2020-07-09

Diagnoses

-ExtensionSequenceDiagnosis[x]
*1Malignant neoplasm of colon, unspecified

Insurances

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

item

Service Item Request Type: Admission Review

Certification Type: Initial

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

Authorization Number: 1122445

Administration Reference Number: 9988311

sequence: 1

careTeamSequence: 1

diagnosisSequence: 1

category: Surgical

productOrService: Under Venous Grafting Only for Coronary Artery Bypass

location: Inpatient Hospital

" }, "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1338", "code" : "E", "display" : "Elective" }] } }, { "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter", "valueReference" : { "reference" : "Encounter/SurgicalEncounterExample" } }, { "extension" : [{ "url" : "category", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1136", "code" : "07" }] } }, { "url" : "indicator", "valueBoolean" : true }, { "url" : "code", "valueCodeableConcept" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1321", "code" : "09" }] } }], "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode" }], "identifier" : [{ "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER", "value" : "16139462398", "assigner" : { "identifier" : { "system" : "http://example.org/USER_ASSIGNED", "value" : "3030240928" } } }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "institutional" }] }, "use" : "preauthorization", "patient" : { "reference" : "Patient/SubscriberExample" }, "created" : "2020-06-24T07:34:00+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/SurgicalPractitionerRoleExample" } }], "supportingInfo" : [{ "sequence" : 1, "category" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes", "code" : "admissionDates" }] }, "timingPeriod" : { "start" : "2020-07-02", "end" : "2020-07-09" } }], "diagnosis" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate", "valueDate" : "2020-06-24" }], "sequence" : 1, "diagnosisCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10-cm", "code" : "C18.9" }] } }], "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" : "AR", "display" : "Admission 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" }], "sequence" : 1, "careTeamSequence" : [1], "diagnosisSequence" : [1], "category" : { "coding" : [{ "system" : "https://codesystem.x12.org/005010/1365", "code" : "2", "display" : "Surgical" }] }, "productOrService" : { "coding" : [{ "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", "code" : "33510", "display" : "Under Venous Grafting Only for Coronary Artery Bypass" }] }, "locationCodeableConcept" : { "coding" : [{ "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code" : "21" }] } }] }