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

## : Referral Authorization Example - JSON Representation

Page standards status: Informative

Raw json | Download

    {
      "resourceType" : "Claim",
      "id" : "ReferralAuthorizationExample",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
        ]
      },
      "text" : {
        "status" : "extensions",
        "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>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>"
      },
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1338",
                "code" : "U",
                "display" : "Urgent"
              }
            ]
          }
        }
      ],
      "identifier" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://www.usps.com/",
                    "code" : "MA"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment",
              "valueString" : "223412"
            }
          ],
          "system" : "urn:trnorg:9012345678",
          "value" : "111099",
          "assigner" : {
            "identifier" : {
              "system" : "http://example.org/USER_ASSIGNED",
              "value" : "9012345678"
            }
          }
        }
      ],
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
            "code" : "professional"
          }
        ]
      },
      "use" : "preauthorization",
      "patient" : {
        🔗 "reference" : "Patient/SubscriberExample"
      },
      "created" : "2005-05-02T11:01:00+05:00",
      "insurer" : {
        🔗 "reference" : "Organization/InsurerExample"
      },
      "provider" : {
        🔗 "reference" : "Organization/UMOExample"
      },
      "priority" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
            "code" : "normal"
          }
        ]
      },
      "careTeam" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
              "valueBoolean" : true
            }
          ],
          "sequence" : 1,
          "provider" : {
            🔗 "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
          }
        }
      ],
      "supportingInfo" : [
        {
          "extension" : [
            {
              "extension" : [
                {
                  "url" : "reportTypeCode",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "https://codesystem.x12.org/005010/755",
                        "code" : "PY",
                        "display" : "Physician's Report"
                      }
                    ]
                  }
                },
                {
                  "url" : "transmissionMethod",
                  "valueCodeableConcept" : {
                    "coding" : [
                      {
                        "system" : "https://codesystem.x12.org/005010/756",
                        "code" : "EL",
                        "display" : "Electronically Only"
                      }
                    ]
                  }
                },
                {
                  "url" : "controlNumber",
                  "valueString" : "111222"
                },
                {
                  "url" : "description",
                  "valueString" : "A procedure note included to provide details of what has been tried before the referral."
                }
              ],
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation"
            }
          ],
          "sequence" : 1,
          "category" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
                "code" : "additionalInformation"
              }
            ]
          },
          "valueReference" : {
            🔗 "reference" : "DocumentReference/DocumentReferenceExample"
          }
        }
      ],
      "diagnosis" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
              "valueDate" : "2021-05-10"
            }
          ],
          "sequence" : 1,
          "diagnosisCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://hl7.org/fhir/sid/icd-10-cm",
                "code" : "G89.4"
              }
            ]
          }
        }
      ],
      "insurance" : [
        {
          "sequence" : 1,
          "focal" : true,
          "coverage" : {
            🔗 "reference" : "Coverage/InsuranceExample"
          }
        }
      ],
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://codesystem.x12.org/005010/1525",
                    "code" : "SC",
                    "display" : "Specialty Care Review"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://codesystem.x12.org/005010/1322",
                    "code" : "I",
                    "display" : "Initial"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",
              "valueIdentifier" : {
                "system" : "http://example.org/ITEM_TRACE_NUMBER",
                "value" : "1122334"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
              "valueString" : "1122445"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
              "valueString" : "9988311"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
              "valueReference" : {
                🔗 "reference" : "ServiceRequest/ReferralRequestExample"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator",
              "valueBoolean" : false
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://codesystem.x12.org/005010/1345",
                    "code" : "2",
                    "display" : "Newly Admitted"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare",
              "valueCodeableConcept" : {
                "coding" : [
                  {
                    "system" : "https://codesystem.x12.org/005010/1337",
                    "code" : "2",
                    "display" : "Intermediate Care Facility (ICF)"
                  }
                ]
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit",
              "valueDecimal" : 100
            }
          ],
          "sequence" : 1,
          "careTeamSequence" : [
            1
          ],
          "diagnosisSequence" : [
            1
          ],
          "category" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1365",
                "code" : "3",
                "display" : "Consultation"
              }
            ]
          },
          "productOrService" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1365",
                "code" : "3",
                "display" : "Consultation"
              }
            ]
          },
          "locationCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
                "code" : "11"
              }
            ]
          }
        }
      ]
    }