Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1
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 2.1.0 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
| Page standards status: Informative |
<Claim xmlns="http://hl7.org/fhir">
<id value="SurgicalAuthorizationRequestExample"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim SurgicalAuthorizationRequestExample</b></p><a name="SurgicalAuthorizationRequestExample"> </a><a name="hcSurgicalAuthorizationRequestExample"> </a><a name="SurgicalAuthorizationRequestExample-en-US"> </a><p><b>LevelOfServiceCode</b>: <span title="Codes:{https://codesystem.x12.org/005010/1338 E}">Elective</span></p><p><b>Extension Definition for Claim.encounter for Version 5.0</b>: <a href="Encounter-SurgicalEncounterExample.html">Encounter: extension = Still a patient; status = planned; class = ambulatory (ActCode#AMB); type = 2; period = 2020-07-02 --> 2020-07-09</a></p><blockquote><p><b>ConditionCode</b></p><ul><li>category: <span title="Codes:{https://codesystem.x12.org/005010/1136 07}">07</span></li><li>indicator: true</li><li>code: <span title="Codes:{https://codesystem.x12.org/005010/1321 09}">09</span></li></ul></blockquote><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/16139462398</p><p><b>status</b>: Active</p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}">Institutional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href="Patient-SubscriberExample.html">JOE SMITH Male, DoB Unknown ( Member Number)</a></p><p><b>created</b>: 2020-06-24 07:34:00+0500</p><p><b>insurer</b>: <a href="Organization-InsurerExample.html">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>provider</b>: <a href="Organization-UMOExample.html">Organization DR. JOE SMITH CORPORATION</a></p><p><b>priority</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}">Normal</span></p><h3>CareTeams</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Provider</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><a href="PractitionerRole-SurgicalPractitionerRoleExample.html">PractitionerRole</a></td></tr></table><h3>SupportingInfos</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Timing[x]</b></td></tr><tr><td style="display: none">*</td><td>1</td><td><span title="Codes:{http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes admissionDates}">Admission Dates</span></td><td>2020-07-02 --> 2020-07-09</td></tr></table><h3>Diagnoses</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style="display: none">*</td><td/><td>1</td><td><span title="Codes:{http://hl7.org/fhir/sid/icd-10-cm C18.9}">Malignant neoplasm of colon, unspecified</span></td></tr></table><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: status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 AR}">Admission Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>ItemTraceNumber</b>: <code>http://example.org/ITEM_TRACE_NUMBER</code>/1122334</p><p><b>AuthorizationNumber</b>: 1122445</p><p><b>AdministrationReferenceNumber</b>: 9988311</p><p><b>sequence</b>: 1</p><p><b>careTeamSequence</b>: 1</p><p><b>diagnosisSequence</b>: 1</p><p><b>category</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 2}">Surgical</span></p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets 33510}">Under Venous Grafting Only for Coronary Artery Bypass</span></p><p><b>location</b>: <span title="Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 21}">21</span></p></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1338"/>
<code value="E"/>
<display value="Elective"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter">
<valueReference>🔗
<reference value="Encounter/SurgicalEncounterExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode">
<extension url="category">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1136"/>
<code value="07"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="indicator">
<valueBoolean value="true"/>
</extension>
<extension url="code">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1321"/>
<code value="09"/>
</coding>
</valueCodeableConcept>
</extension>
</extension>
<identifier>
<system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
<value value="16139462398"/>
<assigner>
<identifier>
<system value="http://example.org/USER_ASSIGNED"/>
<value value="3030240928"/>
</identifier>
</assigner>
</identifier>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
<code value="institutional"/>
</coding>
</type>
<use value="preauthorization"/>
<patient>🔗
<reference value="Patient/SubscriberExample"/>
</patient>
<created value="2020-06-24T07:34:00+05:00"/>
<insurer>🔗
<reference value="Organization/InsurerExample"/>
</insurer>
<provider>🔗
<reference value="Organization/UMOExample"/>
</provider>
<priority>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/processpriority"/>
<code value="normal"/>
</coding>
</priority>
<careTeam>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope">
<valueBoolean value="true"/>
</extension>
<sequence value="1"/>
<provider>🔗
<reference value="PractitionerRole/SurgicalPractitionerRoleExample"/>
</provider>
</careTeam>
<supportingInfo>
<sequence value="1"/>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes"/>
<code value="admissionDates"/>
</coding>
</category>
<timingPeriod>
<start value="2020-07-02"/>
<end value="2020-07-09"/>
</timingPeriod>
</supportingInfo>
<diagnosis>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate">
<valueDate value="2020-06-24"/>
</extension>
<sequence value="1"/>
<diagnosisCodeableConcept>
<coding>
<system value="http://hl7.org/fhir/sid/icd-10-cm"/>
<code value="C18.9"/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<sequence value="1"/>
<focal value="true"/>
<coverage>🔗
<reference value="Coverage/InsuranceExample"/>
</coverage>
</insurance>
<item>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1525"/>
<code value="AR"/>
<display value="Admission Review"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType">
<valueCodeableConcept>
<coding>
<system value="https://codesystem.x12.org/005010/1322"/>
<code value="I"/>
<display value="Initial"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber">
<valueIdentifier>
<system value="http://example.org/ITEM_TRACE_NUMBER"/>
<value value="1122334"/>
</valueIdentifier>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber">
<valueString value="1122445"/>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber">
<valueString value="9988311"/>
</extension>
<sequence value="1"/>
<careTeamSequence value="1"/>
<diagnosisSequence value="1"/>
<category>
<coding>
<system value="https://codesystem.x12.org/005010/1365"/>
<code value="2"/>
<display value="Surgical"/>
</coding>
</category>
<productOrService>
<coding>
<system
value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
<code value="33510"/>
<display
value="Under Venous Grafting Only for Coronary Artery Bypass"/>
</coding>
</productOrService>
<locationCodeableConcept>
<coding>
<system
value="https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set"/>
<code value="21"/>
</coding>
</locationCodeableConcept>
</item>
</Claim>
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.1.0 based on FHIR 4.0.1. Generated 2024-12-20
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