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 Response Example - XML Representation

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<ClaimResponse xmlns="http://hl7.org/fhir">
  <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.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>
  </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>