PAS Inquiry Operation Response Example - TTL Representation - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-snapshot

Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-snapshot - STU 2.2 - Public Review United States of America flag
Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-snapshot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions
: PAS Inquiry Operation Response Example

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Parameters ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "PASClaimInquiryOperationResponseExample"] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:parameter ( [
fhir:name [ fhir:v "responseBundle" ] ;
    ( fhir:Parameters.parameter.resource [
a fhir:Bundle ;
fhir:id [ fhir:v "PASClaimInquiryResponseBundleExample" ] ;
fhir:meta [
        ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle>         ] )       ] ;
fhir:language [ fhir:v "en" ] ;
fhir:identifier [
fhir:system [
fhir:v "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER"^^xsd:anyURI ;
fhir:l <http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER>         ] ;
fhir:value [ fhir:v "5269367" ]       ] ;
fhir:type [ fhir:v "collection" ] ;
fhir:timestamp [ fhir:v "2005-05-02T11:01:00+05:00"^^xsd:dateTime ] ;
      ( fhir:entry [
fhir:fullUrl [
fhir:v "http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample>         ] ;
        ( fhir:resource <http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample> )       ] [
fhir:fullUrl [
fhir:v "http://example.org/fhir/Organization/UMOExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/Organization/UMOExample>         ] ;
        ( fhir:resource <http://example.org/fhir/Organization/UMOExample> )       ] [
fhir:fullUrl [
fhir:v "http://example.org/fhir/Organization/InsurerExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/Organization/InsurerExample>         ] ;
        ( fhir:resource <http://example.org/fhir/Organization/InsurerExample> )       ] [
fhir:fullUrl [
fhir:v "http://example.org/fhir/Coverage/InsuranceExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/Coverage/InsuranceExample>         ] ;
        ( fhir:resource <http://example.org/fhir/Coverage/InsuranceExample> )       ] [
fhir:fullUrl [
fhir:v "http://example.org/fhir/Patient/SubscriberExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/Patient/SubscriberExample>         ] ;
        ( fhir:resource <http://example.org/fhir/Patient/SubscriberExample> )       ] [
fhir:fullUrl [
fhir:v "http://example.org/fhir/Claim/ReferralAuthorizationExample"^^xsd:anyURI ;
fhir:l <http://example.org/fhir/Claim/ReferralAuthorizationExample>         ] ;
        ( fhir:resource <http://example.org/fhir/Claim/ReferralAuthorizationExample> )       ] )     ] )
  ] ) . # 

<http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample> a fhir:ClaimResponse ;
  fhir:id [ fhir:v "PASClaimInquiryResponseExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://example.org/PATIENT_EVENT_TRACE_NUMBER"^^xsd:anyURI ;
fhir:l <http://example.org/PATIENT_EVENT_TRACE_NUMBER>     ] ;
fhir:value [ fhir:v "111099" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [
fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ;
fhir:l <http://example.org/USER_ASSIGNED>         ] ;
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:l <http://terminology.hl7.org/CodeSystem/claim-type>       ] ;
fhir:code [ fhir:v "professional" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
fhir:l fhir:Patient/SubscriberExample ;
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
  ] ; # 
  fhir:created [ fhir:v "2019-07-20T11:01:00+05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:l fhir:Organization/InsurerExample ;
fhir:reference [ fhir:v "Organization/InsurerExample" ]
  ] ; # 
  fhir:request [
fhir:l fhir:Claim/ReferralAuthorizationExample ;
fhir:reference [ fhir:v "Claim/ReferralAuthorizationExample" ]
  ] ; # 
  fhir:outcome [ fhir:v "complete"] ; # 
  fhir:item ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate>       ] ;
fhir:value [
a fhir:Period ;
fhir:start [ fhir:v "2005-05-02"^^xsd:date ] ;
fhir:end [ fhir:v "2005-06-02"^^xsd:date ]       ]     ] ) ;
fhir:itemSequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:adjudication [
      ( fhir:extension [
        ( fhir:extension [
fhir:url [
fhir:v "number"^^xsd:anyURI ;
fhir:l fhir:number           ] ;
fhir:value [
a fhir:String ;
fhir:v "AUTH0001"           ]         ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode>           ] ;
fhir:value [
a fhir:CodeableConcept ;
            ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/306"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/306>               ] ;
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-reviewAction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction>         ]       ] ) ;
fhir:category [
        ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/adjudication>           ] ;
fhir:code [ fhir:v "submitted" ]         ] )       ]     ] )
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v true ] ;
fhir:coverage [
fhir:l fhir:Coverage/InsuranceExample ;
fhir:reference [ fhir:v "Coverage/InsuranceExample" ]     ]
  ] ) . # 

<http://example.org/fhir/Organization/UMOExample> a fhir:Organization ;
  fhir:id [ fhir:v "UMOExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/sid/us-npi>     ] ;
fhir:value [ fhir:v "8189991234" ]
  ] ) ; # 
  fhir:active [ fhir:v true] ; # 
  fhir:type ( [
    ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/98"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/98>       ] ;
fhir:code [ fhir:v "X3" ]     ] )
  ] ) ; # 
  fhir:name [ fhir:v "DR. JOE SMITH CORPORATION"] ; # 
  fhir:address ( [
    ( fhir:line [ fhir:v "111 1ST STREET" ] ) ;
fhir:city [ fhir:v "SAN DIEGO" ] ;
fhir:state [ fhir:v "CA" ] ;
fhir:postalCode [ fhir:v "92101" ] ;
fhir:country [ fhir:v "US" ]
  ] ) . # 

<http://example.org/fhir/Organization/InsurerExample> a fhir:Organization ;
  fhir:id [ fhir:v "InsurerExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/sid/us-npi>     ] ;
fhir:value [ fhir:v "1234567893" ]
  ] ) ; # 
  fhir:active [ fhir:v true] ; # 
  fhir:type ( [
    ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/98"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/98>       ] ;
fhir:code [ fhir:v "PR" ]     ] )
  ] ) ; # 
  fhir:name [ fhir:v "MARYLAND CAPITAL INSURANCE COMPANY"] . # 

<http://example.org/fhir/Coverage/InsuranceExample> a fhir:Coverage ;
  fhir:id [ fhir:v "InsuranceExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:subscriberId [ fhir:v "1122334455"] ; # 
  fhir:beneficiary [
fhir:l fhir:Patient/SubscriberExample ;
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
  ] ; # 
  fhir:relationship [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/subscriber-relationship"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/subscriber-relationship>       ] ;
fhir:code [ fhir:v "self" ]     ] [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1069"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1069>       ] ;
fhir:code [ fhir:v "18" ]     ] )
  ] ; # 
  fhir:payor ( [
fhir:l fhir:Organization/InsurerExample ;
fhir:reference [ fhir:v "Organization/InsurerExample" ]
  ] ) . # 

<http://example.org/fhir/Patient/SubscriberExample> a fhir:Patient ;
  fhir:id [ fhir:v "SubscriberExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:extension ( [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus>     ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/584"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/584>         ] ;
fhir:code [ fhir:v "RU" ]       ] )     ]
  ] ) ; # 
  fhir:identifier ( [
fhir:system [
fhir:v "http://example.org/MIN"^^xsd:anyURI ;
fhir:l <http://example.org/MIN>     ] ;
fhir:value [ fhir:v "12345678901" ]
  ] ) ; # 
  fhir:name ( [
fhir:family [ fhir:v "SMITH" ] ;
    ( fhir:given [ fhir:v "JOE" ] )
  ] ) ; # 
  fhir:gender [ fhir:v "male"] . # 

<http://example.org/fhir/Claim/ReferralAuthorizationExample> a fhir:Claim ;
  fhir:id [ fhir:v "ReferralAuthorizationExample"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim>     ] )
  ] ; # 
  fhir:language [ fhir:v "en"] ; # 
  fhir:extension ( [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode>     ] ;
fhir:value [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1338"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1338>         ] ;
fhir:code [ fhir:v "U" ] ;
fhir:display [ fhir:v "Urgent" ]       ] )     ]
  ] [
    ( fhir:extension [
fhir:url [
fhir:v "applicationSenderCode"^^xsd:anyURI ;
fhir:l fhir:applicationSenderCode       ] ;
fhir:value [
a fhir:String ;
fhir:v "PROVIDERAPP"       ]     ] [
fhir:url [
fhir:v "applicationReceiverCode"^^xsd:anyURI ;
fhir:l fhir:applicationReceiverCode       ] ;
fhir:value [
a fhir:String ;
fhir:v "PAYERAPP"       ]     ] [
fhir:url [
fhir:v "interchangeSenderID"^^xsd:anyURI ;
fhir:l fhir:interchangeSenderID       ] ;
fhir:value [
a fhir:String ;
fhir:v "PROVIDERID"       ]     ] [
fhir:url [
fhir:v "interchangeReceiverID"^^xsd:anyURI ;
fhir:l fhir:interchangeReceiverID       ] ;
fhir:value [
a fhir:String ;
fhir:v "PAYERID"       ]     ] ) ;
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers>     ]
  ] ) ; # 
  fhir:identifier ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction>       ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [
fhir:v "https://www.usps.com/"^^xsd:anyURI ;
fhir:l <https://www.usps.com/>           ] ;
fhir:code [ fhir:v "MA" ]         ] )       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment>       ] ;
fhir:value [
a fhir:String ;
fhir:v "223412"       ]     ] ) ;
fhir:system [
fhir:v "urn:trnorg:9012345678"^^xsd:anyURI ;
fhir:l <urn:trnorg:9012345678>     ] ;
fhir:value [ fhir:v "111099" ] ;
fhir:assigner [
fhir:identifier [
fhir:system [
fhir:v "http://example.org/USER_ASSIGNED"^^xsd:anyURI ;
fhir:l <http://example.org/USER_ASSIGNED>         ] ;
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:l <http://terminology.hl7.org/CodeSystem/claim-type>       ] ;
fhir:code [ fhir:v "professional" ]     ] )
  ] ; # 
  fhir:use [ fhir:v "preauthorization"] ; # 
  fhir:patient [
fhir:l fhir:Patient/SubscriberExample ;
fhir:reference [ fhir:v "Patient/SubscriberExample" ]
  ] ; # 
  fhir:created [ fhir:v "2005-05-02T11:01:00+05:00"^^xsd:dateTime] ; # 
  fhir:insurer [
fhir:l fhir:Organization/InsurerExample ;
fhir:reference [ fhir:v "Organization/InsurerExample" ]
  ] ; # 
  fhir:provider [
fhir:l fhir:Organization/UMOExample ;
fhir:reference [ fhir:v "Organization/UMOExample" ]
  ] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/processpriority>       ] ;
fhir:code [ fhir:v "normal" ]     ] )
  ] ; # 
  fhir:careTeam ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope>       ] ;
fhir:value [
a fhir:Boolean ;
fhir:v true       ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:l fhir:PractitionerRole/ReferralPractitionerRoleExample ;
fhir:reference [ fhir:v "PractitionerRole/ReferralPractitionerRoleExample" ]     ]
  ] ) ; # 
  fhir:supportingInfo ( [
    ( fhir:extension [
      ( fhir:extension [
fhir:url [
fhir:v "reportTypeCode"^^xsd:anyURI ;
fhir:l fhir:reportTypeCode         ] ;
fhir:value [
a fhir:CodeableConcept ;
          ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/755"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/755>             ] ;
fhir:code [ fhir:v "PY" ] ;
fhir:display [ fhir:v "Physician's Report" ]           ] )         ]       ] [
fhir:url [
fhir:v "transmissionMethod"^^xsd:anyURI ;
fhir:l fhir:transmissionMethod         ] ;
fhir:value [
a fhir:CodeableConcept ;
          ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/756"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/756>             ] ;
fhir:code [ fhir:v "EL" ] ;
fhir:display [ fhir:v "Electronically Only" ]           ] )         ]       ] [
fhir:url [
fhir:v "controlNumber"^^xsd:anyURI ;
fhir:l fhir:controlNumber         ] ;
fhir:value [
a fhir:String ;
fhir:v "111222"         ]       ] [
fhir:url [
fhir:v "description"^^xsd:anyURI ;
fhir:l fhir:description         ] ;
fhir:value [
a fhir:String ;
fhir:v "A procedure note included to provide details of what has been tried before the referral."         ]       ] ) ;
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation>       ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
      ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes>         ] ;
fhir:code [ fhir:v "additionalInformation" ]       ] )     ] ;
fhir:value [
a fhir:Reference ;
fhir:l fhir:DocumentReference/DocumentReferenceExample ;
fhir:reference [ fhir:v "DocumentReference/DocumentReferenceExample" ]     ]
  ] ) ; # 
  fhir:diagnosis ( [
    ( fhir:extension [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate>       ] ;
fhir:value [
a fhir:Date ;
fhir:v "2021-05-10"^^xsd:date       ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [
fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/sid/icd-10-cm>         ] ;
fhir:code [ fhir:v "G89.4" ]       ] )     ]
  ] ) ; # 
  fhir:insurance ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:focal [ fhir:v true ] ;
fhir:coverage [
fhir:l fhir:Coverage/InsuranceExample ;
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:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType>       ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1525"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1525>           ] ;
fhir:code [ fhir:v "SC" ] ;
fhir:display [ fhir:v "Specialty Care Review" ]         ] )       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType>       ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1322"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1322>           ] ;
fhir:code [ fhir:v "I" ] ;
fhir:display [ fhir:v "Initial" ]         ] )       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber>       ] ;
fhir:value [
a fhir:Identifier ;
fhir:system [
fhir:v "http://example.org/ITEM_TRACE_NUMBER"^^xsd:anyURI ;
fhir:l <http://example.org/ITEM_TRACE_NUMBER>         ] ;
fhir:value [ fhir:v "1122334" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber>       ] ;
fhir:value [
a fhir:String ;
fhir:v "1122445"       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber>       ] ;
fhir:value [
a fhir:String ;
fhir:v "9988311"       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService>       ] ;
fhir:value [
a fhir:Reference ;
fhir:l fhir:ServiceRequest/ReferralRequestExample ;
fhir:reference [ fhir:v "ServiceRequest/ReferralRequestExample" ]       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator>       ] ;
fhir:value [
a fhir:Boolean ;
fhir:v false       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus>       ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1345"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1345>           ] ;
fhir:code [ fhir:v "2" ] ;
fhir:display [ fhir:v "Newly Admitted" ]         ] )       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare>       ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1337"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1337>           ] ;
fhir:code [ fhir:v "2" ] ;
fhir:display [ fhir:v "Intermediate Care Facility (ICF)" ]         ] )       ]     ] [
fhir:url [
fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit>       ] ;
fhir:value [
a fhir:Decimal ;
fhir:v "100"^^xsd:decimal       ]     ] ) ;
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    ( fhir:careTeamSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
    ( fhir:diagnosisSequence [ fhir:v "1"^^xsd:positiveInteger ] ) ;
fhir:category [
      ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1365>         ] ;
fhir:code [ fhir:v "3" ] ;
fhir:display [ fhir:v "Consultation" ]       ] )     ] ;
fhir:productOrService [
      ( fhir:coding [
fhir:system [
fhir:v "https://codesystem.x12.org/005010/1365"^^xsd:anyURI ;
fhir:l <https://codesystem.x12.org/005010/1365>         ] ;
fhir:code [ fhir:v "3" ] ;
fhir:display [ fhir:v "Consultation" ]       ] )     ] ;
fhir:location [
a fhir:CodeableConcept ;
      ( fhir:coding [
fhir:system [
fhir:v "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"^^xsd:anyURI ;
fhir:l <https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set>         ] ;
fhir:code [ fhir:v "11" ]       ] )     ]
  ] ) . #
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IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.2.0-snapshot based on FHIR 4.0.1. Generated 2026-01-30
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