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 Example - JSON Representation

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{
  "resourceType" : "ClaimResponse",
  "id" : "ReferralAuthorizationResponseExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "text" : {
    "status" : "extensions",
    "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 6:02:00 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>requestor</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>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>"
  },
  "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" : "2005-05-02T11:02:00+05:00",
  "insurer" : {
    "reference" : "Organization/InsurerExample"
  },
  "requestor" : {
    "reference" : "Organization/UMOExample"
  },
  "outcome" : "complete",
  "item" : [
    {
      "extension" : [
        {
          "extension" : [
            {
              "url" : "number",
              "valueString" : "AUTH0001"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "http://codesystem.x12.org/005010/306",
                    "code" : "A1",
                    "display" : "Certified in total"
                  }
                ]
              }
            }
          ],
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate",
          "valuePeriod" : {
            "start" : "2005-05-02",
            "end" : "2005-06-02"
          }
        }
      ],
      "itemSequence" : 1,
      "adjudication" : [
        {
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          }
        }
      ]
    }
  ]
}