Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
{
"resourceType" : "Bundle",
"id" : "PASClaimInquiryBundleExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-request-bundle"
]
},
"identifier" : {
"system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value" : "5269367"
},
"type" : "collection",
"timestamp" : "2005-05-02T11:01:00+05:00",
"entry" : [
{
"fullUrl" : "http://example.org/fhir/Claim/PASClaimInquiryExample",
"resource" : {
"resourceType" : "Claim",
"id" : "PASClaimInquiryExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Claim</b><a name=\"PASClaimInquiryExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Claim "PASClaimInquiryExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim-inquiry.html\">PAS Claim Inquiry</a></p></div><p><b>identifier</b>: id:\u00a0111099</p><p><b>status</b>: active</p><p><b>type</b>: Professional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#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>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href=\"#Organization_InsurerExample\">See above (Organization/InsurerExample)</a></p><p><b>provider</b>: <a href=\"#Organization_UMOExample\">See above (Organization/UMOExample)</a></p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"#Coverage_InsuranceExample\">See above (Coverage/InsuranceExample)</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1322#I)</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: G0154 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#G0154)</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: Health Services Review <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1525#HS)</span></p><p><b>CertificationType</b>: Initial <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1322#I)</span></p><p><b>CertificationIssueDate</b>: 2019-07-01</p><p><b>CertificationEffectiveDate</b>: 2019-07-01</p><p><b>CertificationExpirationDate</b>: 2019-07-31</p><p><b>ReviewActionCode</b>: Certified in total <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (306#A1)</span></p><p><b>ProductOrServiceCodeEnd</b>: B4190 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#B4190)</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: B4184 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (HCPCSReleaseCodeSets#B4184)</span></p></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" : "2019-07-20T11:01:00+05:00",
"insurer" : {
🔗 "reference" : "Organization/InsurerExample"
},
"provider" : {
🔗 "reference" : "Organization/UMOExample"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal"
}
]
},
"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" : "https://codesystem.x12.org/005010/1525",
"code" : "HS",
"display" : "Health Services Review"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1322",
"code" : "I",
"display" : "Initial"
}
]
}
}
],
"sequence" : 1,
"productOrService" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "G0154"
}
]
}
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1525",
"code" : "HS",
"display" : "Health Services Review"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1322",
"code" : "I",
"display" : "Initial"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate",
"valueDate" : "2019-07-01"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate",
"valueDate" : "2019-07-01"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate",
"valueDate" : "2019-07-31"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/306",
"code" : "A1",
"display" : "Certified in total"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "B4190"
}
]
}
}
],
"sequence" : 2,
"productOrService" : {
"coding" : [
{
"system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code" : "B4184"
}
]
}
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/UMOExample",
"resource" : {
"resourceType" : "Organization",
"id" : "UMOExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"UMOExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Organization "UMOExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-requestor.html\">PAS Requestor Organization</a></p></div><p><b>identifier</b>: id:\u00a0<a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-npi.html\">#</a>8189991234</p><p><b>active</b>: true</p><p><b>type</b>: X3 <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (98#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>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "8189991234"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "X3"
}
]
}
],
"name" : "DR. JOE SMITH CORPORATION",
"address" : [
{
"line" : [
"111 1ST STREET"
],
"city" : "SAN DIEGO",
"state" : "CA",
"postalCode" : "92101",
"country" : "US"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Organization/InsurerExample",
"resource" : {
"resourceType" : "Organization",
"id" : "InsurerExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Organization</b><a name=\"InsurerExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Organization "InsurerExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-insurer.html\">PAS Insurer Organization</a></p></div><p><b>identifier</b>: id:\u00a0<a href=\"http://terminology.hl7.org/5.0.0/NamingSystem-npi.html\">#</a>789312</p><p><b>active</b>: true</p><p><b>type</b>: PR <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (98#PR)</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
},
"identifier" : [
{
"system" : "http://hl7.org/fhir/sid/us-npi",
"value" : "789312"
}
],
"active" : true,
"type" : [
{
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/98",
"code" : "PR"
}
]
}
],
"name" : "MARYLAND CAPITAL INSURANCE COMPANY"
}
},
{
"fullUrl" : "http://example.org/fhir/Coverage/InsuranceExample",
"resource" : {
"resourceType" : "Coverage",
"id" : "InsuranceExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Coverage</b><a name=\"InsuranceExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Coverage "InsuranceExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-coverage.html\">PAS Coverage</a></p></div><p><b>status</b>: active</p><p><b>beneficiary</b>: <a href=\"#Patient_SubscriberExample\">See above (Patient/SubscriberExample)</a></p><p><b>payor</b>: <a href=\"#Organization_InsurerExample\">See above (Organization/InsurerExample)</a></p></div>"
},
"status" : "active",
"beneficiary" : {
🔗 "reference" : "Patient/SubscriberExample"
},
"payor" : [
{
🔗 "reference" : "Organization/InsurerExample"
}
]
}
},
{
"fullUrl" : "http://example.org/fhir/Patient/SubscriberExample",
"resource" : {
"resourceType" : "Patient",
"id" : "SubscriberExample",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Patient</b><a name=\"SubscriberExample\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Patient "SubscriberExample" </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-subscriber.html\">PAS Subscriber Patient</a></p></div><p><b>MilitaryStatus</b>: RU <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (584#RU)</span></p><p><b>identifier</b>: id:\u00a012345678901</p><p><b>name</b>: JOE SMITH </p><p><b>gender</b>: male</p></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/584",
"code" : "RU"
}
]
}
}
],
"identifier" : [
{
"system" : "http://example.org/MIN",
"value" : "12345678901"
}
],
"name" : [
{
"family" : "SMITH",
"given" : [
"JOE"
]
}
],
"gender" : "male"
}
}
]
}
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.0.1 based on FHIR 4.0.1. Generated 2023-12-01
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