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

## Example Claim: PAS Claim Inquiry Example

Language: en

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

**identifier**: `http://example.org/PATIENT_EVENT_TRACE_NUMBER`/111099

**status**: Active

**type**: Professional

**use**: Preauthorization

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

**created**: 2019-07-20 11:01:00+0500

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

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

**priority**: Normal

### Insurances

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

> **item****ServiceItemRequestType**: Health Services Review**CertificationType**: Initial**sequence**: 1**productOrService**: G0154

> **item****ServiceItemRequestType**: Health Services Review**CertificationType**: Initial**CertificationIssueDate**: 2019-07-01**CertificationEffectiveDate**: 2019-07-01**CertificationExpirationDate**: 2019-07-31**ReviewActionCode**: Certified in total**ProductOrServiceCodeEnd**: B4190**sequence**: 2**productOrService**: B4184



## Resource Content

```json
{
  "resourceType" : "Claim",
  "id" : "PASClaimInquiryExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry"
    ]
  },
  "language" : "en",
  "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" : "2019-07-20T11:01:00+05:00",
  "insurer" : {
    "reference" : "Organization/InsurerExample"
  },
  "provider" : {
    "reference" : "Organization/UMOExample"
  },
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/processpriority",
        "code" : "normal"
      }
    ]
  },
  "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" : "HS",
                "display" : "Health Services 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"
              }
            ]
          }
        }
      ],
      "sequence" : 1,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "G0154"
          }
        ]
      }
    },
    {
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "https://codesystem.x12.org/005010/1525",
                "code" : "HS",
                "display" : "Health Services 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-itemCertificationIssueDate",
          "valueDate" : "2019-07-01"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate",
          "valueDate" : "2019-07-01"
        },
        {
          "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate",
          "valueDate" : "2019-07-31"
        },
        {
          "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-productOrServiceCodeEnd",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
                "code" : "B4190"
              }
            ]
          }
        }
      ],
      "sequence" : 2,
      "productOrService" : {
        "coding" : [
          {
            "system" : "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
            "code" : "B4184"
          }
        ]
      }
    }
  ]
}

```
