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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: Referral Authorization Example - JSON Representation

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{
  "resourceType" : "Claim",
  "id" : "ReferralAuthorizationExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<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>: May 2, 2005 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>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.html\">Generated Summary: status: active</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>"
  },
  "identifier" : [
    {
      "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
      "value" : "111099",
      "assigner" : {
        "identifier" : {
          "system" : "http://example.org/USER_ASSIGNED",
          "value" : "9012345678"
        }
      }
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "professional"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/SubscriberExample"
  },
  "created" : "2005-05-02T11:01:00+05:00",
  "insurer" : {
    "reference" : "Organization/InsurerExample"
  },
  "provider" : {
    "reference" : "Organization/UMOExample"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "careTeam" : [
    {
      "sequence" : 1,
      "provider" : {
        "reference" : "Practitioner/ReferralPractitionerExample"
      }
    }
  ],
  "diagnosis" : [
    {
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
            "code" : "G89.4"
          }
        ]
      }
    }
  ],
  "insurance" : [
    {
      "sequence" : 1,
      "focal" : true,
      "coverage" : {
        "reference" : "Coverage/InsuranceExample"
      }
    }
  ],
  "item" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://codesystem.x12.org/005010/1525",
                "code" : "SC",
                "display" : "Specialty Care Review"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://codesystem.x12.org/005010/1322",
                "code" : "I",
                "display" : "Initial"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
          "valueReference" : {
            "reference" : "ServiceRequest/ReferralRequestExample"
          }
        }
      ],
      "sequence" : 1,
      "careTeamSequence" : [
        1
      ],
      "diagnosisSequence" : [
        1
      ],
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://codesystem.x12.org/005010/1365",
            "code" : "3",
            "display" : "Consultation"
          }
        ]
      },
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code" : "11"
          }
        ]
      }
    }
  ]
}