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: Surgical Request Authorization Example

Page standards status: Informative

Profile: PAS Claim

LevelOfServiceCode: Elective

Extension Definition for Claim.encounter for Version 5.0: Encounter: extension = Still a patient; status = planned; class = ambulatory (ActCode#AMB); type = 2; period = 2020-07-02 --> 2020-07-09

ConditionCode

  • category: 07
  • indicator: true
  • code: 09

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

status: Active

type: Institutional

use: Preauthorization

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

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: status = active; subscriberId = 1122334455; relationship = Self

item

ServiceItemRequestType: Admission Review

CertificationType: Initial

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

AuthorizationNumber: 1122445

AdministrationReferenceNumber: 9988311

sequence: 1

careTeamSequence: 1

diagnosisSequence: 1

category: Surgical

productOrService: Under Venous Grafting Only for Coronary Artery Bypass

location: Inpatient Hospital