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 Referral Request Example - XML Representation

Page standards status: Informative

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<ServiceRequest xmlns="http://hl7.org/fhir">
  <id value="ReferralRequestExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ServiceRequest ReferralRequestExample</b></p><a name="ReferralRequestExample"> </a><a name="hcReferralRequestExample"> </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-servicerequest.html">PAS Service Request</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Order</p><p><b>code</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>quantity</b>: 1 visit<span style="background: LightGoldenRodYellow"> (Details: UCUM  code1 = '1')</span></p><p><b>subject</b>: <a href="Patient-SubscriberExample.html">JOE SMITH  Male, DoB Unknown ( Member Number)</a></p></div>
  </text>
  <status value="active"/>
  <intent value="order"/>
  <code>
    <coding>
      <system value="https://codesystem.x12.org/005010/1365"/>
      <code value="3"/>
      <display value="Consultation"/>
    </coding>
  </code>
  <quantityQuantity>
    <value value="1"/>
    <unit value="visit"/>
    <system value="http://unitsofmeasure.org"/>
    <code value="1"/>
  </quantityQuantity>
  <subject>🔗 
    <reference value="Patient/SubscriberExample"/>
  </subject>
</ServiceRequest>