Da Vinci Prior Authorization Support (PAS) FHIR IG
1.1.0 - STU 1

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.1.0: STU 1.1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: Homecare Authorization Example - XML Representation

Raw xml | Download



<Claim xmlns="http://hl7.org/fhir">
  <id value="HomecareAuthorizationExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><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">Resource "HomecareAuthorizationExample" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-profile-claim.html">PAS Claim</a></p></div><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-claim-type.html">Claim Type Codes</a>#professional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="Patient-SubscriberExample.html">Patient/SubscriberExample</a> " SMITH"</p><p><b>created</b>: 2019-07-20T11:01:00+05:00</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization/InsurerExample</a> "MARYLAND CAPITAL INSURANCE COMPANY"</p><p><b>provider</b>: <a href="Organization-UMOExample.html">Organization/UMOExample</a> "DR. JOE SMITH CORPORATION"</p><p><b>priority</b>: Normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-processpriority.html">Process Priority Codes</a>#normal)</span></p><h3>Insurances</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td>*</td><td>1</td><td>true</td><td><a href="Coverage-InsuranceExample.html">Coverage/InsuranceExample</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1322#I)</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: G0154 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT&reg;)</a>#G0154)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (1322#I)</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: B4184 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.0.0/CodeSystem-CPT.html">Current Procedural Terminology (CPT&reg;)</a>#B4184)</span></p></blockquote></div>
  </text>
  <identifier>
    <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
    <value value="111099"/>
    <assigner>
      <identifier>
        <system value="http://example.org/USER_ASSIGNED"/>
        <value value="9012345678"/>
      </identifier>
    </assigner>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="professional"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <patient>
    <reference value="Patient/SubscriberExample"/>
  </patient>
  <created value="2019-07-20T11:01:00+05:00"/>
  <insurer>
    <reference value="Organization/InsurerExample"/>
  </insurer>
  <provider>
    <reference value="Organization/UMOExample"/>
  </provider>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
      <code value="normal"/>
    </coding>
  </priority>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/InsuranceExample"/>
    </coverage>
  </insurance>
  <item>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
      <valueCodeableConcept>
        <coding>
          <system value="http://codesystem.x12.org/005010/1525"/>
          <code value="HS"/>
          <display value="Health Services Review"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://codesystem.x12.org/005010/1322"/>
          <code value="I"/>
          <display value="Initial"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <sequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="G0154"/>
      </coding>
    </productOrService>
  </item>
  <item>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
      <valueCodeableConcept>
        <coding>
          <system value="http://codesystem.x12.org/005010/1525"/>
          <code value="HS"/>
          <display value="Health Services Review"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
      <valueCodeableConcept>
        <coding>
          <system value="http://codesystem.x12.org/005010/1322"/>
          <code value="I"/>
          <display value="Initial"/>
        </coding>
      </valueCodeableConcept>
    </extension>
    <sequence value="2"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="B4184"/>
      </coding>
    </productOrService>
  </item>
</Claim>