Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot
This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.2.0-ballot: STU 2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 2.1.0. For a full list of available versions, see the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="RejectionResponseBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"/>
</meta>
<identifier>
<system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
<value value="A12345"/>
</identifier>
<type value="collection"/>
<timestamp value="2005-05-02T11:02:00+05:00"/>
<entry>
<fullUrl
value="http://example.org/fhir/ClaimResponse/RejectionResponseExample"/>
<resource>
<ClaimResponse>
<id value="RejectionResponseExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="ClaimResponse_RejectionResponseExample"> </a><p class="res-header-id"><b>Generated Narrative: ClaimResponse RejectionResponseExample</b></p><a name="RejectionResponseExample"> </a><a name="hcRejectionResponseExample"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-claimresponse.html">PAS Claim Response</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 ( Member Number)</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href="Organization-UMOExample.html">Organization DR. JOE SMITH CORPORATION</a></p><p><b>request</b>: <a href="Claim-ReferralAuthorizationExample.html">Claim: extension = Urgent; identifier = urn:trnorg:9012345678#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td/><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></blockquote></div>
</text>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="111099"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="9012345678"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>🔗
<reference value="Patient/SubscriberExample"/>
</patient>
<created value="2005-05-02T11:02:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<requestor>🔗
<reference value="Organization/UMOExample"/>
</requestor>
<request>🔗
<reference value="Claim/ReferralAuthorizationExample"/>
</request>
<outcome value="complete"/>
<item>
<itemSequence value="1"/>
<adjudication>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/306"/>
<code value="A3"/>
<display value="Not Certified"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<category>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/adjudication"/>
<code value="submitted"/>
</coding>
</category>
</adjudication>
</item>
</ClaimResponse>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/UMOExample"/>
<resource>
<Organization>
<id value="UMOExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_UMOExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization UMOExample</b></p><a name="UMOExample"> </a><a name="hcUMOExample"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-requestor.html">PAS Requestor Organization</a></p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/6.2.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 X3}">X3</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="8189991234"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="X3"/>
</coding>
</type>
<name value="DR. JOE SMITH CORPORATION"/>
<address>
<line value="111 1ST STREET"/>
<city value="SAN DIEGO"/>
<state value="CA"/>
<postalCode value="92101"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/InsurerExample"/>
<resource>
<Organization>
<id value="InsurerExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Organization_InsurerExample"> </a><p class="res-header-id"><b>Generated Narrative: Organization InsurerExample</b></p><a name="InsurerExample"> </a><a name="hcInsurerExample"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-insurer.html">PAS Insurer Organization</a></p></div><p><b>identifier</b>: <a href="http://terminology.hl7.org/6.2.0/NamingSystem-npi.html" title="National Provider Identifier">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes:{https://codesystem.x12.org/005010/98 PR}">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="1234567893"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="PR"/>
</coding>
</type>
<name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/SubscriberExample"/>
<resource>
<Patient>
<id value="SubscriberExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Patient_SubscriberExample"> </a><p class="res-header-id"><b>Generated Narrative: Patient SubscriberExample</b></p><a name="SubscriberExample"> </a><a name="hcSubscriberExample"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-subscriber.html">PAS Subscriber Patient</a></p></div><p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;">JOE SMITH Male, DoB Unknown ( Member Number)</p><hr/><table class="grid"><tr><td style="background-color: #f3f5da" title="A patient's military status."><a href="StructureDefinition-extension-militaryStatus.html"/></td><td colspan="3"><span title="Codes:{https://codesystem.x12.org/005010/584 RU}">RU</span></td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/584"/>
<code value="RU"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="MB"/>
</coding>
</type>
<system value="http://example.org/MIN"/>
<value value="12345678901"/>
</identifier>
<name>
<family value="SMITH"/>
<given value="JOE"/>
</name>
<gender value="male"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/Claim/ReferralAuthorizationExample"/>
<resource>
<Claim>
<id value="ReferralAuthorizationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><a name="Claim_ReferralAuthorizationExample"> </a><p class="res-header-id"><b>Generated Narrative: Claim ReferralAuthorizationExample</b></p><a name="ReferralAuthorizationExample"> </a><a name="hcReferralAuthorizationExample"> </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"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-claim.html">PAS Claim</a></p></div><p><b>LevelOfServiceCode</b>: <span title="Codes:{https://codesystem.x12.org/005010/1338 U}">Urgent</span></p><p><b>identifier</b>: <code>urn:trnorg:9012345678</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 ( Member Number)</a></p><p><b>created</b>: 2005-05-02 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>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><a href="PractitionerRole-ReferralPractitionerRoleExample.html">PractitionerRole: telecom = ph: 4029993456</a></td></tr></table><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><span title="Codes:{http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes additionalInformation}">Additional Information</span></td><td><a href="DocumentReference-DocumentReferenceExample.html">DocumentReference: status = current; type = Physician procedure note; category = Clinical Note</a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm G89.4}">Chronic pain syndrome</span></td></tr></table><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: status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 SC}">Specialty Care Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>ItemTraceNumber</b>: <code>http://example.org/ITEM_TRACE_NUMBER</code>/1122334</p><p><b>AuthorizationNumber</b>: 1122445</p><p><b>AdministrationReferenceNumber</b>: 9988311</p><p><b>RequestedService</b>: <a href="ServiceRequest-ReferralRequestExample.html">ServiceRequest Consultation</a></p><p><b>EPSDTIndicator</b>: false</p><p><b>NursingHomeResidentialStatus</b>: <span title="Codes:{https://codesystem.x12.org/005010/1345 2}">Newly Admitted</span></p><p><b>NursingHomeLevelOfCare</b>: <span title="Codes:{https://codesystem.x12.org/005010/1337 2}">Intermediate Care Facility (ICF)</span></p><p><b>RevenueUnitRateLimit</b>: 100</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>productOrService</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">Office</span></p></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1338"/>
<code value="U"/>
<display value="Urgent"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction">
<valueCodeableConcept>
<coding>
<system value="https://www.usps.com/"/>
<code value="MA"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment">
<valueString value="223412"/>
</extension>
<system value="urn:trnorg:9012345678"/>
<value value="111099"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="9012345678"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="professional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>🔗
<reference value="Patient/SubscriberExample"/>
</patient>
<created value="2005-05-02T11:01:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<provider>🔗
<reference value="Organization/UMOExample"/>
</provider>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<careTeam>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope">
<valueBoolean value="true"/>
</extension>
<sequence value="1"/>
<provider>🔗
<reference
value="PractitionerRole/ReferralPractitionerRoleExample"/>
</provider>
</careTeam>
<supportingInfo>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation">
<extension url="reportTypeCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/755"/>
<code value="PY"/>
<display value="Physician's Report"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="transmissionMethod">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/756"/>
<code value="EL"/>
<display value="Electronically Only"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="controlNumber">
<valueString value="111222"/>
</extension>
<extension url="description">
<valueString
value="A procedure note included to provide details of what has been tried before the referral."/>
</extension>
</extension>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes"/>
<code value="additionalInformation"/>
</coding>
</category>
<valueReference>🔗
<reference value="DocumentReference/DocumentReferenceExample"/>
</valueReference>
</supportingInfo>
<diagnosis>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate">
<valueDate value="2021-05-10"/>
</extension>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G89.4"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="SC"/>
<display value="Specialty Care Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber">
<valueIdentifier>
<system value="http://example.org/ITEM_TRACE_NUMBER"/>
<value value="1122334"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber">
<valueString value="1122445"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber">
<valueString value="9988311"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
<valueReference>🔗
<reference value="ServiceRequest/ReferralRequestExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator">
<valueBoolean value="false"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1345"/>
<code value="2"/>
<display value="Newly Admitted"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1337"/>
<code value="2"/>
<display value="Intermediate Care Facility (ICF)"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit">
<valueDecimal value="100"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</category>
<productOrService>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
</resource>
</entry>
</Bundle>
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.2.0-ballot based on FHIR 4.0.1. Generated 2025-07-30
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