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

: Submit Claim Insurance Example - JSON Representation

Page standards status: Informative

Raw json | Download

{
  "resourceType" : "Coverage",
  "id" : "InsuranceExample",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Coverage InsuranceExample</b></p><a name=\"InsuranceExample\"> </a><a name=\"hcInsuranceExample\"> </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-coverage.html\">PAS Coverage</a></p></div><p><b>status</b>: Active</p><p><b>subscriberId</b>: 1122334455</p><p><b>beneficiary</b>: <a href=\"Patient-SubscriberExample.html\">JOE SMITH  Male, DoB Unknown ( Member Number)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}, {https://codesystem.x12.org/005010/1069 18}\">Self</span></p><p><b>payor</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p></div>"
  },
  "status" : "active",
  "subscriberId" : "1122334455",
  "beneficiary" : {
    🔗 "reference" : "Patient/SubscriberExample"
  },
  "relationship" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
        "code" : "self"
      },
      {
        "system" : "https://codesystem.x12.org/005010/1069",
        "code" : "18"
      }
    ]
  },
  "payor" : [
    {
      🔗 "reference" : "Organization/InsurerExample"
    }
  ]
}