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

## : PAS Claim Inquiry Example - XML Representation

Page standards status: Informative

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    <Claim xmlns="http://hl7.org/fhir">
      <id value="PASClaimInquiryExample"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Claim PASClaimInquiryExample</b></p><a name="PASClaimInquiryExample"> </a><a name="hcPASClaimInquiryExample"> </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-inquiry.html">PAS Claim Inquiry</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>: 2019-07-20 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>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 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}">G0154</span></p></blockquote><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1525 HS}">Health Services Review</span></p><p><b>CertificationType</b>: <span title="Codes:{https://codesystem.x12.org/005010/1322 I}">Initial</span></p><p><b>CertificationIssueDate</b>: 2019-07-01</p><p><b>CertificationEffectiveDate</b>: 2019-07-01</p><p><b>CertificationExpirationDate</b>: 2019-07-31</p><p><b>ReviewActionCode</b>: <span title="Codes:{https://codesystem.x12.org/005010/306 A1}">Certified in total</span></p><p><b>ProductOrServiceCodeEnd</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4190}">B4190</span></p><p><b>sequence</b>: 2</p><p><b>productOrService</b>: <span title="Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}">B4184</span></p></blockquote></div>
      </text>
      <identifier>
        <system value="http://example.org/PATIENT_EVENT_TRACE_NUMBER"/>
        <value value="111099"/>
        <assigner>
          <identifier>
            <system value="http://example.org/USER_ASSIGNED"/>
            <value value="9012345678"/>
          </identifier>
        </assigner>
      </identifier>
      <status value="active"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
          <code value="professional"/>
        </coding>
      </type>
      <use value="preauthorization"/>
      <patient>🔗
        <reference value="Patient/SubscriberExample"/>
      </patient>
      <created value="2019-07-20T11:01:00+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>
      <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="HS"/>
              <display value="Health Services 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>
        <sequence value="1"/>
        <productOrService>
          <coding>
            <system
                    value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
            <code value="G0154"/>
          </coding>
        </productOrService>
      </item>
      <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="HS"/>
              <display value="Health Services 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-itemCertificationIssueDate">
          <valueDate value="2019-07-01"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate">
          <valueDate value="2019-07-01"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate">
          <valueDate value="2019-07-31"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode">
          <valueCodeableConcept>
            <coding>
              <system value="https://codesystem.x12.org/005010/306"/>
              <code value="A1"/>
              <display value="Certified in total"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd">
          <valueCodeableConcept>
            <coding>
              <system
                      value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
              <code value="B4190"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <sequence value="2"/>
        <productOrService>
          <coding>
            <system
                    value="http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets"/>
            <code value="B4184"/>
          </coding>
        </productOrService>
      </item>
    </Claim>