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

## : Authorization Response with Practitioner Requestor and Additional Content Example - XML Representation

Page standards status: Informative

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    <ClaimResponse xmlns="http://hl7.org/fhir">
      <id value="PractitionerRequestorAdditionalContentResponseExample"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ClaimResponse PractitionerRequestorAdditionalContentResponseExample</b></p><a name="PractitionerRequestorAdditionalContentResponseExample"> </a><a name="hcPractitionerRequestorAdditionalContentResponseExample"> </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="PractitionerRole-ReferralPractitionerRoleExample.html">PractitionerRole: telecom = ph: 4029993456</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>: Processing Complete</p><blockquote><p><b>item</b></p><p><b>ItemRequestedServiceDate</b>: 2005-05-02 --&gt; 2005-06-02</p><p><b>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --&gt; 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><ul><li>provider: <a href="Practitioner-ReferralPractitionerExample.html">Practitioner SUSAN WATSON </a></li></ul></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><ul><li>productOrServiceCode: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">Consultation</span></li><li>unitPrice: <span title="US Dollar">$100.00</span> (USD)</li><li>quantity: 1</li></ul></blockquote><p><b>itemSequence</b>: 1</p><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td/><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></blockquote><blockquote><p><b>addItem</b></p><p><b>RevenueCode</b>: <span title="Codes:{https://www.nubc.org/CodeSystem/RevenueCodes 0202}">0202</span></p><p><b>itemSequence</b>: 2</p><p><b>provider</b>: <a href="Practitioner-ReferralPractitionerExample.html">Practitioner SUSAN WATSON </a></p><p><b>productOrService</b>: <span title="Codes:{https://codesystem.x12.org/005010/1365 3}">3</span></p><p><b>quantity</b>: 1</p><h3>UnitPrices</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>100</td><td>United States dollar</td></tr></table><h3>Adjudications</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Extension</b></td><td><b>Category</b></td></tr><tr><td style="display: none">*</td><td/><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}">Submitted Amount</span></td></tr></table></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="2005-05-02T11:02:00+05:00"/>
      <insurer>🔗
        <reference value="Organization/InsurerExample"/>
      </insurer>
      <requestor>🔗
        <reference value="PractitionerRole/ReferralPractitionerRoleExample"/>
      </requestor>
      <request>🔗
        <reference value="Claim/ReferralAuthorizationExample"/>
      </request>
      <outcome value="complete"/>
      <item>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate">
          <valuePeriod>
            <start value="2005-05-02"/>
            <end value="2005-06-02"/>
          </valuePeriod>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate">
          <valueDate value="2005-05-02"/>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod">
          <valuePeriod>
            <start value="2005-05-02"/>
            <end value="2005-06-02"/>
          </valuePeriod>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider">
          <extension url="provider">
            <valueReference>🔗
              <reference value="Practitioner/ReferralPractitionerExample"/>
            </valueReference>
          </extension>
        </extension>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail">
          <extension url="productOrServiceCode">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/1365"/>
                <code value="3"/>
                <display value="Consultation"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <extension url="unitPrice">
            <valueMoney>
              <value value="100"/>
              <currency value="USD"/>
            </valueMoney>
          </extension>
          <extension url="quantity">
            <valueQuantity>
              <value value="1"/>
            </valueQuantity>
          </extension>
        </extension>
        <itemSequence value="1"/>
        <adjudication>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
            <extension url="number">
              <valueString value="AUTH0001"/>
            </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>
          <category>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
              <code value="submitted"/>
            </coding>
          </category>
        </adjudication>
      </item>
      <addItem>
        <extension
                   url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode">
          <valueCodeableConcept>
            <coding>
              <system value="https://www.nubc.org/CodeSystem/RevenueCodes"/>
              <code value="0202"/>
            </coding>
          </valueCodeableConcept>
        </extension>
        <itemSequence value="2"/>
        <provider>🔗
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType">
            <valueCodeableConcept>
              <coding>
                <system value="https://codesystem.x12.org/005010/98"/>
                <code value="P3"/>
              </coding>
            </valueCodeableConcept>
          </extension>
          <reference value="Practitioner/ReferralPractitionerExample"/>
        </provider>
        <productOrService>
          <coding>
            <system value="https://codesystem.x12.org/005010/1365"/>
            <code value="3"/>
          </coding>
        </productOrService>
        <quantity>
          <value value="1"/>
        </quantity>
        <unitPrice>
          <value value="100"/>
          <currency value="USD"/>
        </unitPrice>
        <adjudication>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction">
            <extension url="number">
              <valueString value="AUTH0001"/>
            </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>
          <category>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
              <code value="submitted"/>
            </coding>
          </category>
        </adjudication>
      </addItem>
    </ClaimResponse>