Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot United States of America flag

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

Example Claim: Medical Services Authorization Example

Page standards status: Informative

Profile: PAS Claim

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

status: Active

type: Professional

use: Preauthorization

patient: JOE SMITH Male, DoB Unknown ( Member Number)

created: 2005-05-02 11:01:00+0500

insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY

provider: Organization DR. JOE SMITH CORPORATION

priority: Normal

Insurances

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

item

ServiceItemRequestType: Initial Medical Services Reservation

CertificationType: Initial

AuthorizationNumber: 1122344

AdministrationReferenceNumber: 33441122

sequence: 1

category: Medical Care

productOrService: Established Office Visit

serviced: 2005-05-10

location: Office