# Referral Authorization Response Bundle Example - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-ballot

## Example Bundle: Referral Authorization Response Bundle Example



## Resource Content

```json
{
  "resourceType" : "Bundle",
  "id" : "ReferralAuthorizationResponseBundleExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-response-bundle"
    ]
  },
  "language" : "en",
  "identifier" : {
    "system" : "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
    "value" : "A12345"
  },
  "type" : "collection",
  "timestamp" : "2005-05-02T11:02:00+05:00",
  "entry" : [
    {
      "fullUrl" : "http://example.org/fhir/ClaimResponse/PractitionerRequestorResponseExample",
      "resource" : {
        "resourceType" : "ClaimResponse",
        "id" : "PractitionerRequestorResponseExample",
        "meta" : {
          "profile" : [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
          ]
        },
        "text" : {
          "status" : "extensions",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_PractitionerRequestorResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorResponseExample</b></p><a name=\"PractitionerRequestorResponseExample\"> </a><a name=\"hcPractitionerRequestorResponseExample\"> </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></div>"
        },
        "identifier" : [
          {
            "system" : "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
            "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" : "2005-05-02T11:02:00+05:00",
        "insurer" : {
          "reference" : "Organization/InsurerExample"
        },
        "requestor" : {
          "reference" : "PractitionerRole/ReferralPractitionerRoleExample"
        },
        "request" : {
          "reference" : "Claim/ReferralAuthorizationExample"
        },
        "outcome" : "complete",
        "item" : [
          {
            "extension" : [
              {
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate",
                "valuePeriod" : {
                  "start" : "2005-05-02",
                  "end" : "2005-06-02"
                }
              },
              {
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",
                "valueDate" : "2005-05-02"
              },
              {
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",
                "valuePeriod" : {
                  "start" : "2005-05-02",
                  "end" : "2005-06-02"
                }
              },
              {
                "extension" : [
                  {
                    "url" : "provider",
                    "valueReference" : {
                      "reference" : "Practitioner/ReferralPractitionerExample"
                    }
                  }
                ],
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider"
              },
              {
                "extension" : [
                  {
                    "url" : "productOrServiceCode",
                    "valueCodeableConcept" : {
                      "coding" : [
                        {
                          "system" : "https://codesystem.x12.org/005010/1365",
                          "code" : "3",
                          "display" : "Consultation"
                        }
                      ]
                    }
                  },
                  {
                    "url" : "unitPrice",
                    "valueMoney" : {
                      "value" : 100,
                      "currency" : "USD"
                    }
                  },
                  {
                    "url" : "quantity",
                    "valueQuantity" : {
                      "value" : 1
                    }
                  }
                ],
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail"
              }
            ],
            "itemSequence" : 1,
            "adjudication" : [
              {
                "extension" : [
                  {
                    "extension" : [
                      {
                        "url" : "number",
                        "valueString" : "AUTH0001"
                      },
                      {
                        "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
                        "valueCodeableConcept" : {
                          "coding" : [
                            {
                              "system" : "https://codesystem.x12.org/005010/306",
                              "code" : "A1",
                              "display" : "Certified in total"
                            }
                          ]
                        }
                      }
                    ],
                    "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction"
                  }
                ],
                "category" : {
                  "coding" : [
                    {
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code" : "submitted"
                    }
                  ]
                }
              }
            ]
          }
        ]
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Organization/UMOExample",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "UMOExample",
        "meta" : {
          "profile" : [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_UMOExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization UMOExample</b></p><a name=\"UMOExample\"> </a><a name=\"hcUMOExample\"> </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-requestor.html\">PAS Requestor Organization</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/6.2.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/8189991234</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 X3}\">X3</span></p><p><b>name</b>: DR. JOE SMITH CORPORATION</p><p><b>address</b>: 111 1ST STREET SAN DIEGO CA 92101 US </p></div>"
        },
        "identifier" : [
          {
            "system" : "http://hl7.org/fhir/sid/us-npi",
            "value" : "8189991234"
          }
        ],
        "active" : true,
        "type" : [
          {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/98",
                "code" : "X3"
              }
            ]
          }
        ],
        "name" : "DR. JOE SMITH CORPORATION",
        "address" : [
          {
            "line" : ["111 1ST STREET"],
            "city" : "SAN DIEGO",
            "state" : "CA",
            "postalCode" : "92101",
            "country" : "US"
          }
        ]
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Organization/InsurerExample",
      "resource" : {
        "resourceType" : "Organization",
        "id" : "InsurerExample",
        "meta" : {
          "profile" : [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_InsurerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization InsurerExample</b></p><a name=\"InsurerExample\"> </a><a name=\"hcInsurerExample\"> </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-insurer.html\">PAS Insurer Organization</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/6.2.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/1234567893</p><p><b>active</b>: true</p><p><b>type</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/98 PR}\">PR</span></p><p><b>name</b>: MARYLAND CAPITAL INSURANCE COMPANY</p></div>"
        },
        "identifier" : [
          {
            "system" : "http://hl7.org/fhir/sid/us-npi",
            "value" : "1234567893"
          }
        ],
        "active" : true,
        "type" : [
          {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/98",
                "code" : "PR"
              }
            ]
          }
        ],
        "name" : "MARYLAND CAPITAL INSURANCE COMPANY"
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Patient/SubscriberExample",
      "resource" : {
        "resourceType" : "Patient",
        "id" : "SubscriberExample",
        "meta" : {
          "profile" : [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_SubscriberExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient SubscriberExample</b></p><a name=\"SubscriberExample\"> </a><a name=\"hcSubscriberExample\"> </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-subscriber.html\">PAS Subscriber Patient</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">JOE SMITH  Male, DoB Unknown ( Member Number)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"A patient's military status.\"><a href=\"StructureDefinition-extension-militaryStatus.html\"/></td><td colspan=\"3\"><span title=\"Codes:{https://codesystem.x12.org/005010/584 RU}\">RU</span></td></tr></table></div>"
        },
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus",
            "valueCodeableConcept" : {
              "coding" : [
                {
                  "system" : "https://codesystem.x12.org/005010/584",
                  "code" : "RU"
                }
              ]
            }
          }
        ],
        "identifier" : [
          {
            "type" : {
              "coding" : [
                {
                  "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code" : "MB"
                }
              ]
            },
            "system" : "http://example.org/MIN",
            "value" : "12345678901"
          }
        ],
        "name" : [
          {
            "family" : "SMITH",
            "given" : ["JOE"]
          }
        ],
        "gender" : "male"
      }
    },
    {
      "fullUrl" : "http://example.org/fhir/Practitioner/ReferralPractitionerExample",
      "resource" : {
        "resourceType" : "Practitioner",
        "id" : "ReferralPractitionerExample",
        "meta" : {
          "profile" : [
            "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner"
          ]
        },
        "text" : {
          "status" : "generated",
          "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_ReferralPractitionerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner ReferralPractitionerExample</b></p><a name=\"ReferralPractitionerExample\"> </a><a name=\"hcReferralPractitionerExample\"> </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-practitioner.html\">PAS Practitioner</a></p></div><p><b>identifier</b>: <a href=\"http://terminology.hl7.org/6.2.0/NamingSystem-npi.html\" title=\"National Provider Identifier\">United States National Provider Identifier</a>/1234567893</p><p><b>name</b>: SUSAN WATSON </p></div>"
        },
        "identifier" : [
          {
            "system" : "http://hl7.org/fhir/sid/us-npi",
            "value" : "1234567893"
          }
        ],
        "name" : [
          {
            "family" : "WATSON",
            "given" : ["SUSAN"]
          }
        ]
      }
    }
  ]
}

```
