Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

PA Referral Request example - XML Representation

(back to narrative)

Raw xml 


<Bundle xmlns="http://hl7.org/fhir">
  <id value="pa-request-example-referral"/>
  <identifier>
    <system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
    <value value="A12345"/>
  </identifier>
  <type value="collection"/>
  <timestamp value="2005-05-02T11:01:00+05:00"/>
  <entry>
    <fullUrl value="http://example.org/fhir/Claim/1"/>
    <resource>
      <Claim>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Specialty Care Review <span style="background: LightGoldenRodYellow">(Details : {http://example.org/UM_REQUEST_CATEGORY_CODE code 'SC' = 'SC', given as 'Specialty Care Review'})</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="Patient/1">Patient/1</a></p><p><b>created</b>: Jul 20, 2019 12:00:00 AM</p><p><b>insurer</b>: <a href="Organization/1">Organization/1</a></p><p><b>provider</b>: <a href="PractitionerRole/1">PractitionerRole/1</a></p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow">(Details : {http://terminology/hl7.org/CodeSystem/processpriority code 'normal' = 'normal', given as 'Normal'})</span></p><p><b>prescription</b>: see requested service extension</p><p><b>facility</b>: <a href="Location/1">Location/1</a></p><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td><a href="Condition/1">Condition/1</a></td></tr></table><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href="Coverage/1">Coverage/1</a></td></tr></table></div>
        </text>
        <identifier>
          <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
          <value value="111099"/>
          <assigner>
            <reference value="Organization/3"/>
          </assigner>
        </identifier>
        <status value="active"/>
        <type>
          <coding>
            <system value="http://example.org/UM_REQUEST_CATEGORY_CODE"/>
            <code value="SC"/>
            <display value="Specialty Care Review"/>
          </coding>
        </type>
        <use value="preauthorization">
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
            <valueCode value="I"/>
          </extension>
        </use>
        <patient>
          <reference value="Patient/1"/>
        </patient>
        <created value="2019-07-20"/>
        <insurer>
          <reference value="Organization/1"/>
        </insurer>
        <provider>
          <reference value="PractitionerRole/1"/>
        </provider>
        <priority>
          <coding>
            <system
                    value="http://terminology/hl7.org/CodeSystem/processpriority"/>
            <code value="normal"/>
            <display value="Normal"/>
          </coding>
        </priority>
        <prescription>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
            <valueReference>
              <reference value="ServiceRequest/1"/>
            </valueReference>
          </extension>
          <display value="see requested service extension"/>
        </prescription>
        <facility>
          <reference value="Location/1"/>
        </facility>
        <diagnosis>
          <sequence value="1"/>
          <diagnosisReference>
            <reference value="Condition/1"/>
          </diagnosisReference>
        </diagnosis>
        <insurance>
          <sequence value="1"/>
          <focal value="true"/>
          <coverage>
            <reference value="Coverage/1"/>
          </coverage>
        </insurance>
      </Claim>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/1"/>
    <resource>
      <Organization>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: ETIN = 789312</p><p><b>type</b>: Utilization Management Organization <span style="background: LightGoldenRodYellow">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code 'X3' = 'X3', given as 'Utilization Management Organization'})</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="46"/>
              <display value="ETIN"/>
            </coding>
          </type>
          <system value="http://example.org/ETIN"/>
          <value value="789312"/>
        </identifier>
        <type>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="X3"/>
            <display value="Utilization Management Organization"/>
          </coding>
        </type>
        <name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/PractitionerRole/1"/>
    <resource>
      <PractitionerRole>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>practitioner</b>: <a href="Practitioner/1">Practitioner/1</a></p><p><b>code</b>: Provider <span style="background: LightGoldenRodYellow">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code '1P' = '1P', given as 'Provider'})</span></p></div>
        </text>
        <practitioner>
          <reference value="Practitioner/1"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="1P"/>
            <display value="Provider"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/1"/>
    <resource>
      <Practitioner>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: ETIN = 8189991234</p><p><b>name</b>: JAMES GARDENER </p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="46"/>
              <display value="ETIN"/>
            </coding>
          </type>
          <system value="http://example.org/ETIN"/>
          <value value="8189991234"/>
        </identifier>
        <name>
          <family value="GARDENER"/>
          <given value="JAMES"/>
        </name>
      </Practitioner>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Coverage/1"/>
    <resource>
      <Coverage>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href="Patient/1">Patient/1</a></p><p><b>payor</b>: <a href="Organization/1">Organization/1</a></p></div>
        </text>
        <status value="active"/>
      <!--  This is actual the subscriber but beneficiary is mandatory  -->
        <beneficiary>
          <reference value="Patient/1"/>
        </beneficiary>
      <!--  Payor is mandatory but we don't actually have one so the insurer organization is specified here  -->
        <payor>
          <reference value="Organization/1"/>
        </payor>
      </Coverage>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Patient/1"/>
    <resource>
      <Patient>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>identifier</b>: Member Identification Number = 12345678901</p><p><b>name</b>: JOE SMITH </p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="MI"/>
              <display value="Member Identification Number"/>
            </coding>
          </type>
          <system value="http://example.org/MIN"/>
          <value value="12345678901"/>
        </identifier>
        <name>
          <family value="SMITH"/>
          <given value="JOE"/>
        </name>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Organization/3"/>
    <resource>
      <Organization>
        <id value="3"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 3</p><p><b>identifier</b>: 9012345678</p></div>
        </text>
        <identifier>
          <system value="http://example.org/USER_ASSIGNED"/>
          <value value="9012345678"/>
        </identifier>
      </Organization>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/ServiceRequest/1"/>
    <resource>
      <ServiceRequest>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>code</b>: Consultation <span style="background: LightGoldenRodYellow">(Details : {http://example.org/SERVICE_TYPE_CODE code '3' = '3', given as 'Consultation'})</span></p><p><b>quantity</b>: 1 VS</p><p><b>subject</b>: <a href="Patient/1">Patient/1</a></p><p><b>performer</b>: <a href="PractitionerRole/2">PractitionerRole/2</a></p></div>
        </text>
        <status value="active"/>
        <intent value="plan"/>
        <code>
          <coding>
            <system value="http://example.org/SERVICE_TYPE_CODE"/>
            <code value="3"/>
            <display value="Consultation"/>
          </coding>
        </code>
        <quantityQuantity>
          <value value="1"/>
          <unit value="VS"/>
        </quantityQuantity>
        <subject>
          <reference value="Patient/1"/>
        </subject>
        <performer>
          <reference value="PractitionerRole/2"/>
        </performer>
      </ServiceRequest>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Location/1"/>
    <resource>
      <Location>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>type</b>: 11 <span style="background: LightGoldenRodYellow">(Details : {http://example.org/Place-of-Service-Codes code '11' = '11)</span></p></div>
        </text>
        <type>
          <coding>
            <system value="http://example.org/Place-of-Service-Codes"/>
            <code value="11"/>
          </coding>
        </type>
      </Location>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Condition/1"/>
    <resource>
      <Condition>
        <id value="1"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 1</p><p><b>code</b>: 410.90 <span style="background: LightGoldenRodYellow">(Details : {http://hl7.org/fhir/sid/icd-9-cm code '410.90' = '410.90)</span></p><p><b>subject</b>: <a href="Patient/1">Patient/1</a></p><p><b>recordedDate</b>: Apr 30, 2005 12:00:00 AM</p></div>
        </text>
        <code>
          <coding>
            <system value="http://hl7.org/fhir/sid/icd-9-cm"/>
            <code value="410.90"/>
          </coding>
        </code>
        <subject>
          <reference value="Patient/1"/>
        </subject>
        <recordedDate value="2005-04-30"/>
      </Condition>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/PractitionerRole/2"/>
    <resource>
      <PractitionerRole>
        <id value="2"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 2</p><p><b>practitioner</b>: <a href="Practitioner/2">Practitioner/2</a></p><p><b>code</b>: Service Provider <span style="background: LightGoldenRodYellow">(Details : {http://example.org/ENTITY_IDENTIFIER_CODE code 'SJ' = 'SJ', given as 'Service Provider'})</span></p></div>
        </text>
        <practitioner>
          <reference value="Practitioner/2"/>
        </practitioner>
        <code>
          <coding>
            <system value="http://example.org/ENTITY_IDENTIFIER_CODE"/>
            <code value="SJ"/>
            <display value="Service Provider"/>
          </coding>
        </code>
      </PractitionerRole>
    </resource>
  </entry>
  <entry>
    <fullUrl value="http://example.org/fhir/Practitioner/2"/>
    <resource>
      <Practitioner>
        <id value="2"/>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 2</p><p><b>identifier</b>: SSN = 987654321</p><p><b>name</b>: SUSAN WATSON </p><p><b>telecom</b>: ph: 4029993456</p></div>
        </text>
        <identifier>
          <type>
            <coding>
              <system value="http://example.org/IDENTIFICATION_CODE_QUALIFIER"/>
              <code value="34"/>
              <display value="SSN"/>
            </coding>
          </type>
          <system value="http://example.org/SSN"/>
          <value value="987654321"/>
        </identifier>
        <name>
          <family value="WATSON"/>
          <given value="SUSAN"/>
        </name>
        <telecom>
          <system value="phone"/>
          <value value="4029993456"/>
        </telecom>
      </Practitioner>
    </resource>
  </entry>
</Bundle>