Error Response Bundle Example - TTL Representation - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.1

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 2.2.1 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
: Error Response Bundle Example

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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 -------------------------------------------------------------------

<http://hl7.org/fhir/Bundle/ErrorResponseBundleExample> a fhir:Bundle ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "ErrorResponseBundleExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:Bundle.identifier [
     fhir:Identifier.system [ fhir:value "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER" ] ;
     fhir:Identifier.value [ fhir:value "A12345" ]
  ] ;
  fhir:Bundle.type [ fhir:value "collection"] ;
  fhir:Bundle.timestamp [ fhir:value "2005-05-02T11:02:00+05:00"^^xsd:dateTime] ;
  fhir:Bundle.entry [
     fhir:index -1 ;
     fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/ClaimResponse/ErrorResponseExample" ] ;
     fhir:Bundle.entry.resource <http://example.org/fhir/ClaimResponse/ErrorResponseExample>
  ], [
     fhir:index -1 ;
     fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/UMOExample" ] ;
     fhir:Bundle.entry.resource <http://example.org/fhir/Organization/UMOExample>
  ], [
     fhir:index -1 ;
     fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Organization/InsurerExample" ] ;
     fhir:Bundle.entry.resource <http://example.org/fhir/Organization/InsurerExample>
  ], [
     fhir:index -1 ;
     fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Patient/SubscriberExample" ] ;
     fhir:Bundle.entry.resource <http://example.org/fhir/Patient/SubscriberExample>
  ], [
     fhir:index -1 ;
     fhir:Bundle.entry.fullUrl [ fhir:value "http://example.org/fhir/Claim/ReferralAuthorizationExample" ] ;
     fhir:Bundle.entry.resource <http://example.org/fhir/Claim/ReferralAuthorizationExample>
  ] .

<http://example.org/fhir/ClaimResponse/ErrorResponseExample> a fhir:ClaimResponse ;
  fhir:Resource.id [ fhir:value "ErrorResponseExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_ErrorResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse ErrorResponseExample</b></p><a name=\"ErrorResponseExample\"> </a><a name=\"hcErrorResponseExample\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claimresponse.html\">PAS Claim Response</a></p></div><blockquote><p><b>Transmission Identifiers</b></p><ul><li>applicationSenderCode: PAYERAPP</li><li>applicationReceiverCode: PROVIDERAPP</li><li>interchangeSenderID: PAYERID</li><li>interchangeReceiverID: PROVIDERID</li></ul></blockquote><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/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\">JOE SMITH  Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2005-05-02 11:02:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p><p><b>requestor</b>: <a href=\"Organization-UMOExample.html\">Organization DR. JOE SMITH CORPORATION</a></p><p><b>request</b>: <a href=\"Claim-ReferralAuthorizationExample.html\">Claim: extension = Urgent,; identifier = urn:trnorg:9012345678#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal</a></p><p><b>outcome</b>: Error</p><blockquote><p><b>error</b></p><p><b>code</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/901 04}\">04</span></p></blockquote><blockquote><p><b>error</b></p><blockquote><p><b>Error Element</b></p><ul><li>error: 2010A-NM103</li></ul></blockquote><p><b>Error Path</b>: Bundle.entry[1].Organization.name</p><p><b>Error Follow-up Action</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/889 C}\">C</span></p><p><b>code</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/901 T4}\">T4</span></p></blockquote></div>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "applicationSenderCode" ] ;
       fhir:Extension.valueString [ fhir:value "PAYERAPP" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "applicationReceiverCode" ] ;
       fhir:Extension.valueString [ fhir:value "PROVIDERAPP" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "interchangeSenderID" ] ;
       fhir:Extension.valueString [ fhir:value "PAYERID" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "interchangeReceiverID" ] ;
       fhir:Extension.valueString [ fhir:value "PROVIDERID" ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers" ]
  ] ;
  fhir:ClaimResponse.identifier [
     fhir:index -1 ;
     fhir:Identifier.system [ fhir:value "http://example.org/PATIENT_EVENT_TRACE_NUMBER" ] ;
     fhir:Identifier.value [ fhir:value "111099" ] ;
     fhir:Identifier.assigner [
       fhir:Reference.identifier [
         fhir:Identifier.system [ fhir:value "http://example.org/USER_ASSIGNED" ] ;
         fhir:Identifier.value [ fhir:value "9012345678" ]
       ]
     ]
  ] ;
  fhir:ClaimResponse.status [ fhir:value "active"] ;
  fhir:ClaimResponse.type [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ;
       fhir:Coding.code [ fhir:value "professional" ]
     ]
  ] ;
  fhir:ClaimResponse.use [ fhir:value "preauthorization"] ;
  fhir:ClaimResponse.patient [
     fhir:link <http://hl7.org/fhir/Patient/SubscriberExample> ;
     fhir:Reference.reference [ fhir:value "Patient/SubscriberExample" ]
  ] ;
  fhir:ClaimResponse.created [ fhir:value "2005-05-02T11:02:00+05:00"^^xsd:dateTime] ;
  fhir:ClaimResponse.insurer [
     fhir:link <http://hl7.org/fhir/Organization/InsurerExample> ;
     fhir:Reference.reference [ fhir:value "Organization/InsurerExample" ]
  ] ;
  fhir:ClaimResponse.requestor [
     fhir:link <http://hl7.org/fhir/Organization/UMOExample> ;
     fhir:Reference.reference [ fhir:value "Organization/UMOExample" ]
  ] ;
  fhir:ClaimResponse.request [
     fhir:link <http://hl7.org/fhir/Claim/ReferralAuthorizationExample> ;
     fhir:Reference.reference [ fhir:value "Claim/ReferralAuthorizationExample" ]
  ] ;
  fhir:ClaimResponse.outcome [ fhir:value "error"] ;
  fhir:ClaimResponse.error [
     fhir:index -1 ;
     fhir:ClaimResponse.error.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/901" ] ;
         fhir:Coding.code [ fhir:value "04" ]
       ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Element.extension [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "error" ] ;
         fhir:Extension.valueString [ fhir:value "2010A-NM103" ]
       ] ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath" ] ;
       fhir:Extension.valueString [ fhir:value "Bundle.entry[1].Organization.name" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/889" ] ;
           fhir:Coding.code [ fhir:value "C" ]
         ]
       ]
     ] ;
     fhir:ClaimResponse.error.code [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/901" ] ;
         fhir:Coding.code [ fhir:value "T4" ]
       ]
     ]
  ] .

<http://hl7.org/fhir/Patient/SubscriberExample> a fhir:Patient .

<http://hl7.org/fhir/Organization/InsurerExample> a fhir:Organization .

<http://hl7.org/fhir/Organization/UMOExample> a fhir:Organization .

<http://hl7.org/fhir/Claim/ReferralAuthorizationExample> a fhir:Claim .

<http://example.org/fhir/Organization/UMOExample> a fhir:Organization ;
  fhir:Resource.id [ fhir:value "UMOExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_UMOExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization UMOExample</b></p><a name=\"UMOExample\"> </a><a name=\"hcUMOExample\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-requestor.html\">PAS Requestor Organization</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/5.5.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 X3}\">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>"
  ] ;
  fhir:Organization.identifier [
     fhir:index -1 ;
     fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/sid/us-npi" ] ;
     fhir:Identifier.value [ fhir:value "8189991234" ]
  ] ;
  fhir:Organization.active [ fhir:value "true"^^xsd:boolean] ;
  fhir:Organization.type [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/98" ] ;
       fhir:Coding.code [ fhir:value "X3" ]
     ]
  ] ;
  fhir:Organization.name [ fhir:value "DR. JOE SMITH CORPORATION"] ;
  fhir:Organization.address [
     fhir:index -1 ;
     fhir:Address.line [
       fhir:value "111 1ST STREET" ;
       fhir:index -1
     ] ;
     fhir:Address.city [ fhir:value "SAN DIEGO" ] ;
     fhir:Address.state [ fhir:value "CA" ] ;
     fhir:Address.postalCode [ fhir:value "92101" ] ;
     fhir:Address.country [ fhir:value "US" ]
  ] .

<http://example.org/fhir/Organization/InsurerExample> a fhir:Organization ;
  fhir:Resource.id [ fhir:value "InsurerExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_InsurerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization InsurerExample</b></p><a name=\"InsurerExample\"> </a><a name=\"hcInsurerExample\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-insurer.html\">PAS Insurer Organization</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/5.5.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 PR}\">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
  ] ;
  fhir:Organization.identifier [
     fhir:index -1 ;
     fhir:Identifier.system [ fhir:value "http://hl7.org/fhir/sid/us-npi" ] ;
     fhir:Identifier.value [ fhir:value "1234567893" ]
  ] ;
  fhir:Organization.active [ fhir:value "true"^^xsd:boolean] ;
  fhir:Organization.type [
     fhir:index -1 ;
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/98" ] ;
       fhir:Coding.code [ fhir:value "PR" ]
     ]
  ] ;
  fhir:Organization.name [ fhir:value "MARYLAND CAPITAL INSURANCE COMPANY"] .

<http://example.org/fhir/Patient/SubscriberExample> a fhir:Patient ;
  fhir:Resource.id [ fhir:value "SubscriberExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_SubscriberExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient SubscriberExample</b></p><a name=\"SubscriberExample\"> </a><a name=\"hcSubscriberExample\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-subscriber.html\">PAS Subscriber Patient</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">JOE SMITH  Male, DoB Unknown ( http://example.org/MIN#12345678901)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"A patient's military status.\"><a href=\"StructureDefinition-extension-militaryStatus.html\">Military Status</a></td><td colspan=\"3\"><span title=\"Codes:{https://codesystem.x12.org/005010/584 RU}\">RU</span></td></tr></table></div>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus" ] ;
     fhir:Extension.valueCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/584" ] ;
         fhir:Coding.code [ fhir:value "RU" ]
       ]
     ]
  ] ;
  fhir:Patient.identifier [
     fhir:index -1 ;
     fhir:Identifier.system [ fhir:value "http://example.org/MIN" ] ;
     fhir:Identifier.value [ fhir:value "12345678901" ]
  ] ;
  fhir:Patient.name [
     fhir:index -1 ;
     fhir:HumanName.family [ fhir:value "SMITH" ] ;
     fhir:HumanName.given [
       fhir:value "JOE" ;
       fhir:index -1
     ]
  ] ;
  fhir:Patient.gender [ fhir:value "male"] .

<http://example.org/fhir/Claim/ReferralAuthorizationExample> a fhir:Claim ;
  fhir:Resource.id [ fhir:value "ReferralAuthorizationExample"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim" ;
       fhir:index -1 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_ReferralAuthorizationExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim ReferralAuthorizationExample</b></p><a name=\"ReferralAuthorizationExample\"> </a><a name=\"hcReferralAuthorizationExample\"> </a><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\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-profile-claim.html\">PAS Claim</a></p></div><p><b>Level of Service Code</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1338 U}\">Urgent</span></p><blockquote><p><b>Transmission Identifiers</b></p><ul><li>applicationSenderCode: PROVIDERAPP</li><li>applicationReceiverCode: PAYERAPP</li><li>interchangeSenderID: PROVIDERID</li><li>interchangeReceiverID: PAYERID</li></ul></blockquote><p><b>identifier</b>: <code>urn:trnorg:9012345678</code>/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\">JOE SMITH  Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2005-05-02 11:01:00+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-ReferralPractitionerRoleExample.html\">PractitionerRole: telecom = ph: 4029993456</a></td></tr></table><h3>SupportingInfos</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Sequence</b></td><td><b>Category</b></td><td><b>Value[x]</b></td></tr><tr><td style=\"display: none\">*</td><td/><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes additionalInformation}\">Additional Information</span></td><td><a href=\"DocumentReference-DocumentReferenceExample.html\">DocumentReference: status = current; type = Physician procedure note; category = Clinical Note</a></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 G89.4}\">Chronic pain syndrome</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: identifier = Member Number; status = active; subscriberId = 1122334455; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>Service Item Request Type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 SC}\">Specialty Care Review</span></p><p><b>Certification Type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>Item Trace Number</b>: <code>http://example.org/ITEM_TRACE_NUMBER</code>/1122334</p><p><b>Authorization Number</b>: 1122445</p><p><b>Administration Reference Number</b>: 9988311</p><p><b>Requested Service</b>: <a href=\"ServiceRequest-ReferralRequestExample.html\">ServiceRequest Consultation</a></p><p><b>EPSDT Indicator</b>: false</p><p><b>Nursing Home Residential Status</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1345 2}\">Newly Admitted</span></p><p><b>Nursing Home Level of Care</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1337 2}\">Intermediate Care Facility (ICF)</span></p><p><b>Revenue Unit Rate Limit</b>: 100</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 3}\">Consultation</span></p><p><b>productOrService</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</span></p><p><b>location</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set 11}\">Office</span></p></blockquote></div>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index -1 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode" ] ;
     fhir:Extension.valueCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1338" ] ;
         fhir:Coding.code [ fhir:value "U" ] ;
         fhir:Coding.display [ fhir:value "Urgent" ]
       ]
     ]
  ], [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "applicationSenderCode" ] ;
       fhir:Extension.valueString [ fhir:value "PROVIDERAPP" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "applicationReceiverCode" ] ;
       fhir:Extension.valueString [ fhir:value "PAYERAPP" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "interchangeSenderID" ] ;
       fhir:Extension.valueString [ fhir:value "PROVIDERID" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "interchangeReceiverID" ] ;
       fhir:Extension.valueString [ fhir:value "PAYERID" ]
     ] ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers" ]
  ] ;
  fhir:Claim.identifier [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://www.usps.com/" ] ;
           fhir:Coding.code [ fhir:value "MA" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment" ] ;
       fhir:Extension.valueString [ fhir:value "223412" ]
     ] ;
     fhir:Identifier.system [ fhir:value "urn:trnorg:9012345678" ] ;
     fhir:Identifier.value [ fhir:value "111099" ] ;
     fhir:Identifier.assigner [
       fhir:Reference.identifier [
         fhir:Identifier.system [ fhir:value "http://example.org/USER_ASSIGNED" ] ;
         fhir:Identifier.value [ fhir:value "9012345678" ]
       ]
     ]
  ] ;
  fhir:Claim.status [ fhir:value "active"] ;
  fhir:Claim.type [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ;
       fhir:Coding.code [ fhir:value "professional" ]
     ]
  ] ;
  fhir:Claim.use [ fhir:value "preauthorization"] ;
  fhir:Claim.patient [
     fhir:link <http://hl7.org/fhir/Patient/SubscriberExample> ;
     fhir:Reference.reference [ fhir:value "Patient/SubscriberExample" ]
  ] ;
  fhir:Claim.created [ fhir:value "2005-05-02T11:01:00+05:00"^^xsd:dateTime] ;
  fhir:Claim.insurer [
     fhir:link <http://hl7.org/fhir/Organization/InsurerExample> ;
     fhir:Reference.reference [ fhir:value "Organization/InsurerExample" ]
  ] ;
  fhir:Claim.provider [
     fhir:link <http://hl7.org/fhir/Organization/UMOExample> ;
     fhir:Reference.reference [ fhir:value "Organization/UMOExample" ]
  ] ;
  fhir:Claim.priority [
     fhir:CodeableConcept.coding [
       fhir:index -1 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ] ;
       fhir:Coding.code [ fhir:value "normal" ]
     ]
  ] ;
  fhir:Claim.careTeam [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope" ] ;
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
     ] ;
     fhir:Claim.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:Claim.careTeam.provider [
       fhir:link <http://hl7.org/fhir/PractitionerRole/ReferralPractitionerRoleExample> ;
       fhir:Reference.reference [ fhir:value "PractitionerRole/ReferralPractitionerRoleExample" ]
     ]
  ] ;
  fhir:Claim.supportingInfo [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Element.extension [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "reportTypeCode" ] ;
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index -1 ;
             fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/755" ] ;
             fhir:Coding.code [ fhir:value "PY" ] ;
             fhir:Coding.display [ fhir:value "Physician's Report" ]
           ]
         ]
       ], [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "transmissionMethod" ] ;
         fhir:Extension.valueCodeableConcept [
           fhir:CodeableConcept.coding [
             fhir:index -1 ;
             fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/756" ] ;
             fhir:Coding.code [ fhir:value "EL" ] ;
             fhir:Coding.display [ fhir:value "Electronically Only" ]
           ]
         ]
       ], [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "controlNumber" ] ;
         fhir:Extension.valueString [ fhir:value "111222" ]
       ], [
         fhir:index -1 ;
         fhir:Extension.url [ fhir:value "description" ] ;
         fhir:Extension.valueString [ fhir:value "A procedure note included to provide details of what has been tried before the referral." ]
       ] ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation" ]
     ] ;
     fhir:Claim.supportingInfo.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:Claim.supportingInfo.category [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes" ] ;
         fhir:Coding.code [ fhir:value "additionalInformation" ]
       ]
     ] ;
     fhir:Claim.supportingInfo.valueReference [
       fhir:link <http://hl7.org/fhir/DocumentReference/DocumentReferenceExample> ;
       fhir:Reference.reference [ fhir:value "DocumentReference/DocumentReferenceExample" ]
     ]
  ] ;
  fhir:Claim.diagnosis [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate" ] ;
       fhir:Extension.valueDate [ fhir:value "2021-05-10"^^xsd:date ]
     ] ;
     fhir:Claim.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:Claim.diagnosis.diagnosisCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ] ;
         fhir:Coding.code [ fhir:value "G89.4" ]
       ]
     ]
  ] ;
  fhir:Claim.insurance [
     fhir:index -1 ;
     fhir:Claim.insurance.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:Claim.insurance.focal [ fhir:value "true"^^xsd:boolean ] ;
     fhir:Claim.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/InsuranceExample> ;
       fhir:Reference.reference [ fhir:value "Coverage/InsuranceExample" ]
     ]
  ] ;
  fhir:Claim.item [
     fhir:index -1 ;
     fhir:Element.extension [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1525" ] ;
           fhir:Coding.code [ fhir:value "SC" ] ;
           fhir:Coding.display [ fhir:value "Specialty Care Review" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1322" ] ;
           fhir:Coding.code [ fhir:value "I" ] ;
           fhir:Coding.display [ fhir:value "Initial" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber" ] ;
       fhir:Extension.valueIdentifier [
         fhir:Identifier.system [ fhir:value "http://example.org/ITEM_TRACE_NUMBER" ] ;
         fhir:Identifier.value [ fhir:value "1122334" ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber" ] ;
       fhir:Extension.valueString [ fhir:value "1122445" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber" ] ;
       fhir:Extension.valueString [ fhir:value "9988311" ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService" ] ;
       fhir:Extension.valueReference [
         fhir:link <http://hl7.org/fhir/ServiceRequest/ReferralRequestExample> ;
         fhir:Reference.reference [ fhir:value "ServiceRequest/ReferralRequestExample" ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator" ] ;
       fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1345" ] ;
           fhir:Coding.code [ fhir:value "2" ] ;
           fhir:Coding.display [ fhir:value "Newly Admitted" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare" ] ;
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index -1 ;
           fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1337" ] ;
           fhir:Coding.code [ fhir:value "2" ] ;
           fhir:Coding.display [ fhir:value "Intermediate Care Facility (ICF)" ]
         ]
       ]
     ], [
       fhir:index -1 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit" ] ;
       fhir:Extension.valueDecimal [ fhir:value "100"^^xsd:decimal ]
     ] ;
     fhir:Claim.item.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:Claim.item.careTeamSequence [
       fhir:value "1"^^xsd:positiveInteger ;
       fhir:index -1
     ] ;
     fhir:Claim.item.diagnosisSequence [
       fhir:value "1"^^xsd:positiveInteger ;
       fhir:index -1
     ] ;
     fhir:Claim.item.category [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1365" ] ;
         fhir:Coding.code [ fhir:value "3" ] ;
         fhir:Coding.display [ fhir:value "Consultation" ]
       ]
     ] ;
     fhir:Claim.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1365" ] ;
         fhir:Coding.code [ fhir:value "3" ] ;
         fhir:Coding.display [ fhir:value "Consultation" ]
       ]
     ] ;
     fhir:Claim.item.locationCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index -1 ;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set" ] ;
         fhir:Coding.code [ fhir:value "11" ]
       ]
     ]
  ] .

<http://hl7.org/fhir/PractitionerRole/ReferralPractitionerRoleExample> a fhir:PractitionerRole .

<http://hl7.org/fhir/DocumentReference/DocumentReferenceExample> a fhir:DocumentReference .

<http://hl7.org/fhir/Coverage/InsuranceExample> a fhir:Coverage .

<http://hl7.org/fhir/ServiceRequest/ReferralRequestExample> a fhir:ServiceRequest .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Bundle/ErrorResponseBundleExample.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/Bundle/ErrorResponseBundleExample.ttl> .