# Surgical Request Authorization Example - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-ballot

## Example Claim: Surgical Request Authorization Example

Language: en

Profile: [PAS Claim](StructureDefinition-profile-claim.md)

**LevelOfServiceCode**: Elective

**Extension Definition for Claim.encounter for Version 5.0**: [Encounter: extension = Still a patient; status = planned; class = ambulatory (ActCode#AMB); type = 2; period = 2020-07-02 --> 2020-07-09](Encounter-SurgicalEncounterExample.md)

> **ConditionCode**
* category: 07
* indicator: true
* code: 09

**identifier**: `http://example.org/PATIENT_EVENT_TRACE_NUMBER`/16139462398

**status**: Active

**type**: Institutional

**use**: Preauthorization

**patient**: [JOE SMITH Male, DoB Unknown ( Member Number)](Patient-SubscriberExample.md)

**created**: 2020-06-24 07:34:00+0500

**insurer**: [Organization MARYLAND CAPITAL INSURANCE COMPANY](Organization-InsurerExample.md)

**provider**: [Organization DR. JOE SMITH CORPORATION](Organization-UMOExample.md)

**priority**: Normal

### CareTeams

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Extension** | **Sequence** | **Provider** |
| * |  | 1 | [PractitionerRole: telecom = ph: 4029993456](PractitionerRole-SurgicalPractitionerRoleExample.md) |

### SupportingInfos

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Sequence** | **Category** | **Timing[x]** |
| * | 1 | Admission Dates | 2020-07-02 --> 2020-07-09 |

### Diagnoses

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Extension** | **Sequence** | **Diagnosis[x]** |
| * |  | 1 | Malignant neoplasm of colon, unspecified |

### Insurances

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Sequence** | **Focal** | **Coverage** |
| * | 1 | true | [Coverage: status = active; subscriberId = 1122334455; relationship = Self](Coverage-InsuranceExample.md) |

> **item****ServiceItemRequestType**: Admission Review**CertificationType**: Initial**ItemTraceNumber**: `http://example.org/ITEM_TRACE_NUMBER`/1122334**AuthorizationNumber**: 1122445**AdministrationReferenceNumber**: 9988311**sequence**: 1**careTeamSequence**: 1**diagnosisSequence**: 1**category**: Surgical**productOrService**: Under Venous Grafting Only for Coronary Artery Bypass**location**: Inpatient Hospital



## Resource Content

```json
{
  "resourceType" : "Claim",
  "id" : "SurgicalAuthorizationRequestExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
    ]
  },
  "language" : "en",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://codesystem.x12.org/005010/1338",
            "code" : "E",
            "display" : "Elective"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter",
      "valueReference" : {
        "reference" : "Encounter/SurgicalEncounterExample"
      }
    },
    {
      "extension" : [
        {
          "url" : "category",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1136",
                "code" : "07"
              }
            ]
          }
        },
        {
          "url" : "indicator",
          "valueBoolean" : true
        },
        {
          "url" : "code",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1321",
                "code" : "09"
              }
            ]
          }
        }
      ],
      "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode"
    }
  ],
  "identifier" : [
    {
      "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
      "value" : "16139462398",
      "assigner" : {
        "identifier" : {
          "system" : "http://example.org/USER_ASSIGNED",
          "value" : "3030240928"
        }
      }
    }
  ],
  "status" : "active",
  "type" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
        "code" : "institutional"
      }
    ]
  },
  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/SubscriberExample"
  },
  "created" : "2020-06-24T07:34:00+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/SurgicalPractitionerRoleExample"
      }
    }
  ],
  "supportingInfo" : [
    {
      "sequence" : 1,
      "category" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
            "code" : "admissionDates"
          }
        ]
      },
      "timingPeriod" : {
        "start" : "2020-07-02",
        "end" : "2020-07-09"
      }
    }
  ],
  "diagnosis" : [
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
          "valueDate" : "2020-06-24"
        }
      ],
      "sequence" : 1,
      "diagnosisCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/sid/icd-10-cm",
            "code" : "C18.9"
          }
        ]
      }
    }
  ],
  "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" : "AR",
                "display" : "Admission 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"
        }
      ],
      "sequence" : 1,
      "careTeamSequence" : [1],
      "diagnosisSequence" : [1],
      "category" : {
        "coding" : [
          {
            "system" : "https://codesystem.x12.org/005010/1365",
            "code" : "2",
            "display" : "Surgical"
          }
        ]
      },
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "33510",
            "display" : "Under Venous Grafting Only for Coronary Artery Bypass"
          }
        ]
      },
      "locationCodeableConcept" : {
        "coding" : [
          {
            "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
            "code" : "21"
          }
        ]
      }
    }
  ]
}

```
