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

: Referral Authorization Response Bundle Example - XML Representation

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<Bundle xmlns="http://hl7.org/fhir">
  <id value="ReferralAuthorizationResponseBundleExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"/>
  </meta>
  <type value="collection"/>
  <timestamp value="2005-05-02T11:02:00+05:00"/>
  <entry>
    <fullUrl
             value="http://example.org/fhir/ClaimResponse/ReferralAuthorizationResponseExample"/>
    <resource>
      <ClaimResponse>
        <id value="ReferralAuthorizationResponseExample"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
        </meta>
        <text>
          <status value="extensions"/>
          <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 6:02:00 AM</p><p><b>insurer</b>: <a href="#Organization_InsurerExample">See above (Organization/InsurerExample)</a></p><p><b>requestor</b>: <a href="#Organization_UMOExample">See above (Organization/UMOExample)</a></p><p><b>outcome</b>: complete</p><blockquote><p><b>item</b></p><blockquote><p><b>ReviewAction</b></p><h3>Urls</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>value</b>: AUTH0001</p><h3>Urls</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>value</b>: <span title="Codes: {http://codesystem.x12.org/005010/306 A1}">Certified in total</span></p></blockquote><p><b>AuthorizedDate</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class="grid"><tr><td>-</td><td><b>Category</b></td></tr><tr><td>*</td><td><span title="Codes: {http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></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="2005-05-02T11:02:00+05:00"/>
        <insurer>
          <reference value="Organization/InsurerExample"/>
        </insurer>
        <requestor>
          <reference value="Organization/UMOExample"/>
        </requestor>
        <outcome value="complete"/>
        <item>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
            <extension url="number">
              <valueString value="AUTH0001"/>
            </extension>
            <extension
                       url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
              <valueCodeableConcept>
                <coding>
                  <system value="http://codesystem.x12.org/005010/306"/>
                  <code value="A1"/>
                  <display value="Certified in total"/>
                </coding>
              </valueCodeableConcept>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate">
            <valuePeriod>
              <start value="2005-05-02"/>
              <end value="2005-06-02"/>
            </valuePeriod>
          </extension>
          <itemSequence value="1"/>
          <adjudication>
            <category>
              <coding>
                <system
                        value="http://terminology.hl7.org/CodeSystem/adjudication"/>
                <code value="submitted"/>
              </coding>
            </category>
          </adjudication>
        </item>
      </ClaimResponse>
    </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/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>
</Bundle>