Da Vinci Prior Authorization Support (PAS) FHIR IG
1.0.0 - STU 1
Da Vinci Prior Authorization Support (PAS) FHIR IG
1.0.0 - STU 1
This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
<Bundle xmlns="http://hl7.org/fhir">
<id value="ReferralAuthorizationBundleExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"/>
</meta>
<identifier>
<system value="http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"/>
<value value="A12345"/>
</identifier>
<type value="collection"/>
<timestamp value="2005-05-02T11:01:00+05:00"/>
<entry>
<fullUrl value="http://example.org/fhir/Claim/ReferralAuthorizationExample"/>
<resource>
<Claim>
<id value="ReferralAuthorizationExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 111099</p><p><b>status</b>: active</p><p><b>type</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/claim-type professional}">Professional</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href="#Patient_SubscriberExample">See above (Patient/SubscriberExample)</a></p><p><b>created</b>: May 2, 2005 6:01:00 AM</p><p><b>insurer</b>: <a href="#Organization_InsurerExample">See above (Organization/InsurerExample)</a></p><p><b>provider</b>: <a href="#Organization_UMOExample">See above (Organization/UMOExample)</a></p><p><b>priority</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>CareTeams</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td>*</td><td>1</td><td><a href="Practitioner-ReferralPractitionerExample.html">Generated Summary: id: 987654321; SUSAN WATSON ; Phone: 4029993456</a></td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td>-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td>*</td><td>1</td><td><span title="Codes: {http://hl7.org/fhir/sid/icd-10-cm G89.4}">Chronic pain syndrome</span></td></tr></table><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">See above (Coverage/InsuranceExample)</a></td></tr></table><h3>Items</h3><table class="grid"><tr><td>-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>CareTeamSequence</b></td><td><b>DiagnosisSequence</b></td><td><b>ProductOrService</b></td><td><b>Location[x]</b></td></tr><tr><td>*</td><td>, , </td><td>1</td><td>1</td><td>1</td><td><span title="Codes: {http://codesystem.x12.org/005010/1365 3}">Consultation</span></td><td><span title="Codes: {https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}">11</span></td></tr></table></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="2005-05-02T11:01:00+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>
<careTeam>
<sequence value="1"/>
<provider>
<reference value="Practitioner/ReferralPractitionerExample"/>
</provider>
</careTeam>
<diagnosis>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="G89.4"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<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="SC"/>
<display value="Specialty Care 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>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService">
<valueReference>
<reference value="ServiceRequest/ReferralRequestExample"/>
</valueReference>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<productOrService>
<coding>
<system value="http://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="11"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/UMOExample"/>
<resource>
<Organization>
<id value="UMOExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes: {https://codesystem.x12.org/005010/98 X3}">X3</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="8189991234"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="X3"/>
</coding>
</type>
<name value="DR. JOE SMITH CORPORATION"/>
<address>
<line value="111 1ST STREET"/>
<city value="SAN DIEGO"/>
<state value="CA"/>
<postalCode value="92101"/>
<country value="US"/>
</address>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Organization/InsurerExample"/>
<resource>
<Organization>
<id value="InsurerExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 789312</p><p><b>active</b>: true</p><p><b>type</b>: <span title="Codes: {https://codesystem.x12.org/005010/98 PR}">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>
</text>
<identifier>
<system value="http://hl7.org/fhir/sid/us-npi"/>
<value value="789312"/>
</identifier>
<active value="true"/>
<type>
<coding>
<system value="https://codesystem.x12.org/005010/98"/>
<code value="PR"/>
</coding>
</type>
<name value="MARYLAND CAPITAL INSURANCE COMPANY"/>
</Organization>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Coverage/InsuranceExample"/>
<resource>
<Coverage>
<id value="InsuranceExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href="#Patient_SubscriberExample">See above (Patient/SubscriberExample)</a></p><p><b>payor</b>: <a href="#Organization_InsurerExample">See above (Organization/InsurerExample)</a></p></div>
</text>
<status value="active"/>
<beneficiary>
<reference value="Patient/SubscriberExample"/>
</beneficiary>
<payor>
<reference value="Organization/InsurerExample"/>
</payor>
</Coverage>
</resource>
</entry>
<entry>
<fullUrl value="http://example.org/fhir/Patient/SubscriberExample"/>
<resource>
<Patient>
<id value="SubscriberExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><p><b>MilitaryStatus</b>: <span title="Codes: {https://codesystem.x12.org/005010/584 RU}">RU</span></p><p><b>identifier</b>: id: 12345678901</p><p><b>name</b>: JOE SMITH </p><p><b>gender</b>: male</p></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/584"/>
<code value="RU"/>
</coding>
</valueCodeableConcept>
</extension>
<identifier>
<system value="http://example.org/MIN"/>
<value value="12345678901"/>
</identifier>
<name>
<family value="SMITH"/>
<given value="JOE"/>
</name>
<gender value="male"/>
</Patient>
</resource>
</entry>
<entry>
<fullUrl
value="http://example.org/fhir/ServiceRequest/ReferralRequestExample"/>
<resource>
<ServiceRequest>
<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><b>Generated Narrative</b></p><p><b>status</b>: active</p><p><b>intent</b>: order</p><p><b>code</b>: <span title="Codes: {http://codesystem.x12.org/005010/1365 3}">Consultation</span></p><p><b>quantity</b>: 1 {visit}</p><p><b>subject</b>: <a href="#Patient_SubscriberExample">See above (Patient/SubscriberExample)</a></p></div>
</text>
<status value="active"/>
<intent value="order"/>
<code>
<coding>
<system value="http://codesystem.x12.org/005010/1365"/>
<code value="3"/>
<display value="Consultation"/>
</coding>
</code>
<quantityQuantity>
<value value="1"/>
<system value="http://unitsofmeasure.org"/>
<code value="{visit}"/>
</quantityQuantity>
<subject>
<reference value="Patient/SubscriberExample"/>
</subject>
</ServiceRequest>
</resource>
</entry>
</Bundle>
IG © 2020+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pas#1.0.0 based on FHIR 4.0.1. Generated 2020-12-20
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