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 - XML Representation

Page standards status: Informative

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