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
: PAS Claim Inquiry Example - TTL Representation
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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Claim ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "PASClaimInquiryExample"] ; #
fhir:meta [
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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: 111099</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.html\">Patient/SubscriberExample</a> " SMITH"</p><p><b>created</b>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization/InsurerExample</a> "MARYLAND CAPITAL INSURANCE COMPANY"</p><p><b>provider</b>: <a href=\"Organization-UMOExample.html\">Organization/UMOExample</a> "DR. JOE SMITH CORPORATION"</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.html\">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>"
] ; #
fhir:identifier ( [
fhir:system [ fhir:v "http://example.org/PATIENT_EVENT_TRACE_NUMBER"^^xsd:anyURI ] ;
fhir:value [ fhir:v "111099" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [ fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ] ;
fhir:value [ fhir:v "9012345678" ] ] ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "professional" ] ] )
] ; #
fhir:use [ fhir:v "preauthorization"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
] ; #
fhir:created [ fhir:v "2019-07-20T11:01:00+05:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/InsurerExample" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/UMOExample" ]
] ; #
fhir:priority [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ] ] )
] ; #
fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/InsuranceExample" ] ]
] ) ; #
fhir:item ( [
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ] ;
fhir:code [ fhir:v "HS" ] ;
fhir:display [ fhir:v "Health Services Review" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ] ] ) ] ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ;
fhir:code [ fhir:v "G0154" ] ] ) ]
] [
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ] ;
fhir:code [ fhir:v "HS" ] ;
fhir:display [ fhir:v "Health Services Review" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2019-07-01"^^xsd:date ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2019-07-01"^^xsd:date ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2019-07-31"^^xsd:date ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/306"^^xsd:anyURI ] ;
fhir:code [ fhir:v "A1" ] ;
fhir:display [ fhir:v "Certified in total" ] ] ) ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ;
fhir:code [ fhir:v "B4190" ] ] ) ] ] ) ;
fhir:sequence [ fhir:v "2"^^xsd:positiveInteger ] ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"^^xsd:anyURI ] ;
fhir:code [ fhir:v "B4184" ] ] ) ]
] ) . #
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