Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot

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-ballot 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 - TTL Representation

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

    <http://example.org/fhir/ClaimResponse/ErrorResponseExample> a fhir:ClaimResponse ;
      fhir:id [ fhir:v "ErrorResponseExample"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"^^xsd:anyURI ;
    fhir:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir: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><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 ( Member Number)</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><p><b>ErrorElement</b>: 2010A-NM103</p><p><b>ErrorPath</b>: Bundle.entry[1].Organization.name</p><p><b>ErrorFollowupAction</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>"^^rdf:XMLLiteral
      ] ; #
      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 "2005-05-02T11:02:00+05:00"^^xsd:dateTime] ; #
      fhir:insurer [
    fhir:reference [ fhir:v "Organization/InsurerExample" ]
      ] ; #
      fhir:requestor [
    fhir:reference [ fhir:v "Organization/UMOExample" ]
      ] ; #
      fhir:request [
    fhir:reference [ fhir:v "Claim/ReferralAuthorizationExample" ]
      ] ; #
      fhir:outcome [ fhir:v "error"] ; #
      fhir:error ( [
    fhir:code [
          ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/901"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "04" ]       ] )     ]
      ] [
        ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:string ;
    fhir:v "2010A-NM103"       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:string ;
    fhir:v "Bundle.entry[1].Organization.name"       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/889"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "C" ]         ] )       ]     ] ) ;
    fhir:code [
          ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/901"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "T4" ]       ] )     ]
      ] ) . #

    <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:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir: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/6.2.0/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>"^^rdf:XMLLiteral
      ] ; #
      fhir:identifier ( [
    fhir:system [ fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ] ;
    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: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:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir: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/6.2.0/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>"^^rdf:XMLLiteral
      ] ; #
      fhir:identifier ( [
    fhir:system [ fhir:v "http://hl7.org/fhir/sid/us-npi"^^xsd:anyURI ] ;
    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:code [ fhir:v "PR" ]     ] )
      ] ) ; #
      fhir:name [ fhir:v "MARYLAND CAPITAL INSURANCE COMPANY"] . #

    <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:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "generated" ] ;
    fhir: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 ( Member Number)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"A patient's military status.\"><a href=\"StructureDefinition-extension-militaryStatus.html\"/></td><td colspan=\"3\"><span title=\"Codes:{https://codesystem.x12.org/005010/584 RU}\">RU</span></td></tr></table></div>"^^rdf:XMLLiteral
      ] ; #
      fhir:extension ( [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
          ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/584"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "RU" ]       ] )     ]
      ] ) ; #
      fhir:identifier ( [
    fhir:type [
          ( fhir:coding [
    fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "MB" ]       ] )     ] ;
    fhir:system [ fhir:v "http://example.org/MIN"^^xsd:anyURI ] ;
    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:link <http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim>     ] )
      ] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir: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>LevelOfServiceCode</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1338 U}\">Urgent</span></p><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 ( Member Number)</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: 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 SC}\">Specialty Care 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>RequestedService</b>: <a href=\"ServiceRequest-ReferralRequestExample.html\">ServiceRequest Consultation</a></p><p><b>EPSDTIndicator</b>: false</p><p><b>NursingHomeResidentialStatus</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1345 2}\">Newly Admitted</span></p><p><b>NursingHomeLevelOfCare</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1337 2}\">Intermediate Care Facility (ICF)</span></p><p><b>RevenueUnitRateLimit</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>"^^rdf:XMLLiteral
      ] ; #
      fhir:extension ( [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
          ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/1338"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "U" ] ;
    fhir:display [ fhir:v "Urgent" ]       ] )     ]
      ] ) ; #
      fhir:identifier ( [
        ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [ fhir:v "https://www.usps.com/"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "MA" ]         ] )       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:string ;
    fhir:v "223412"       ]     ] ) ;
    fhir:system [ fhir:v "urn:trnorg:9012345678"^^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 "2005-05-02T11:01:00+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:careTeam ( [
        ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:boolean ;
    fhir:v true       ]     ] ) ;
    fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    fhir:provider [
    fhir:reference [ fhir:v "PractitionerRole/ReferralPractitionerRoleExample" ]     ]
      ] ) ; #
      fhir:supportingInfo ( [
        ( fhir:extension [
          ( fhir:extension [
    fhir:url [ fhir:v "reportTypeCode"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
              ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/755"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "PY" ] ;
    fhir:display [ fhir:v "Physician's Report" ]           ] )         ]       ] [
    fhir:url [ fhir:v "transmissionMethod"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
              ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/756"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "EL" ] ;
    fhir:display [ fhir:v "Electronically Only" ]           ] )         ]       ] [
    fhir:url [ fhir:v "controlNumber"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:string ;
    fhir:v "111222"         ]       ] [
    fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
    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: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:code [ fhir:v "additionalInformation" ]       ] )     ] ;
    fhir:value [
    a fhir:Reference ;
    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: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:code [ fhir:v "G89.4" ]       ] )     ]
      ] ) ; #
      fhir:insurance ( [
    fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
    fhir:focal [ fhir:v true ] ;
    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 "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: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-itemTraceNumber"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Identifier ;
    fhir:system [ fhir:v "http://example.org/ITEM_TRACE_NUMBER"^^xsd:anyURI ] ;
    fhir:value [ fhir:v "1122334" ]       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber"^^xsd:anyURI ] ;
    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:value [
    a fhir:string ;
    fhir:v "9988311"       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Reference ;
    fhir:reference [ fhir:v "ServiceRequest/ReferralRequestExample" ]       ]     ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator"^^xsd:anyURI ] ;
    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:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/1345"^^xsd:anyURI ] ;
    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:value [
    a fhir:CodeableConcept ;
            ( fhir:coding [
    fhir:system [ fhir:v "https://codesystem.x12.org/005010/1337"^^xsd:anyURI ] ;
    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: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: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: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:code [ fhir:v "11" ]       ] )     ]
      ] ) . #