Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.1 - STU 2.2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.1 - STU 2.2
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
| Page standards status: Informative |
@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/Claim/ReferralAuthorizationExample> a fhir:Claim ;
fhir:nodeRole fhir:treeRoot ;
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\"><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/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/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/Claim/ReferralAuthorizationExample.ttl> a owl:Ontology ;
owl:imports fhir:fhir.ttl ;
owl:versionIRI <http://build.fhir.org/Claim/ReferralAuthorizationExample.ttl> .
IG © 2020+ HL7 International / Financial Management.
Package hl7.fhir.us.davinci-pas#2.2.1 based on FHIR 4.0.1.
Generated
2026-08-28
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