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: Referral Authorization Example

Page standards status: Informative

Profile: PAS Claim

LevelOfServiceCode: Urgent

identifier: urn:trnorg:9012345678/111099

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

CareTeams

-ExtensionSequenceProvider
*1PractitionerRole: telecom = ph: 4029993456

SupportingInfos

-ExtensionSequenceCategoryValue[x]
*1Additional InformationDocumentReference: status = current; type = Physician procedure note; category = Clinical Note

Diagnoses

-ExtensionSequenceDiagnosis[x]
*1Chronic pain syndrome

Insurances

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

item

ServiceItemRequestType: Specialty Care Review

CertificationType: Initial

ItemTraceNumber: http://example.org/ITEM_TRACE_NUMBER/1122334

AuthorizationNumber: 1122445

AdministrationReferenceNumber: 9988311

RequestedService: ServiceRequest Consultation

EPSDTIndicator: false

NursingHomeResidentialStatus: Newly Admitted

NursingHomeLevelOfCare: Intermediate Care Facility (ICF)

RevenueUnitRateLimit: 100

sequence: 1

careTeamSequence: 1

diagnosisSequence: 1

category: Consultation

productOrService: Consultation

location: Office