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

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: Homecare Authorization Differential Update Example - XML Representation

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<Claim xmlns="http://hl7.org/fhir">
  <id value="HomecareAuthorizationDifferentialExample"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update"/>
    <security>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationValue"/>
      <code value="SUBSETTED"/>
    </security>
  </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.html">Generated Summary: id: 12345678901; JOE SMITH ; gender: male</a></p><p><b>created</b>: Jul 20, 2019 6:01:00 AM</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Generated Summary: id: 789312; active; <span title="Codes: {https://codesystem.x12.org/005010/98 PR}">PR</span>; name: MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>provider</b>: <a href="Organization-UMOExample.html">Generated Summary: id: 8189991234; active; <span title="Codes: {https://codesystem.x12.org/005010/98 X3}">X3</span>; name: DR. JOE SMITH CORPORATION</a></p><p><b>priority</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/processpriority normal}">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">Generated Summary: status: active</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes: {http://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes: {http://codesystem.x12.org/005010/1322 I}">Initial</span></p><h3>ModifierExtension[http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled]s</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt B4184}">B4184</span></p></blockquote><blockquote><p><b>item</b></p><p><b>InfoChanged</b>: added</p><p><b>ServiceItemRequestType</b>: <span title="Codes: {http://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes: {http://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>sequence</b>: 3</p><p><b>productOrService</b>: <span title="Codes: {http://www.ama-assn.org/go/cpt B4185}">B4185</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>
    <modifierExtension
                       url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled">
      <valueBoolean value="true"/>
    </modifierExtension>
    <sequence value="2"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="B4184"/>
      </coding>
    </productOrService>
  </item>
  <item>
    <extension
               url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged">
      <valueCode value="added"/>
    </extension>
    <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="3"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="B4185"/>
      </coding>
    </productOrService>
  </item>
</Claim>