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

## : Rejection Response Bundle Example

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    {
      "resourceType" : "Bundle",
      "id" : "RejectionResponseBundleExample",
      "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/RejectionResponseExample",
          "resource" : {
            "resourceType" : "ClaimResponse",
            "id" : "RejectionResponseExample",
            "meta" : {
              "profile" : [
                🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
              ]
            },
            "language" : "en",
            "text" : {
              "status" : "extensions",
              "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_RejectionResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse RejectionResponseExample</b></p><a name=\"RejectionResponseExample\"> </a><a name=\"hcRejectionResponseExample\"> </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><blockquote><p><b>ClaimResponseReviewer</b></p><ul><li>wasHumanReviewedFlag: true</li></ul></blockquote><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=\"Organization-UMOExample.html\">Organization DR. JOE SMITH CORPORATION</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>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>"
            },
            "extension" : [
              {
                "extension" : [
                  {
                    "url" : "wasHumanReviewedFlag",
                    "valueBoolean" : true
                  }
                ],
                "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer"
              }
            ],
            "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" : "Organization/UMOExample"
            },
            "request" : {
              🔗 "reference" : "Claim/ReferralAuthorizationExample"
            },
            "outcome" : "complete",
            "item" : [
              {
                "itemSequence" : 1,
                "adjudication" : [
                  {
                    "extension" : [
                      {
                        "extension" : [
                          {
                            "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",
                            "valueCodeableConcept" : {
                              "coding" : [
                                {
                                  "system" : "https://codesystem.x12.org/005010/306",
                                  "code" : "A3",
                                  "display" : "Not Certified"
                                }
                              ]
                            }
                          }
                        ],
                        "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"
              ]
            },
            "language" : "en",
            "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"
              ]
            },
            "language" : "en",
            "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"
              ]
            },
            "language" : "en",
            "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/Claim/ReferralAuthorizationExample",
          "resource" : {
            "resourceType" : "Claim",
            "id" : "ReferralAuthorizationExample",
            "meta" : {
              "profile" : [
                🔗 "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
              ]
            },
            "language" : "en",
            "text" : {
              "status" : "extensions",
              "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_ReferralAuthorizationExample\"> </a><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"
                    }
                  ]
                }
              }
            ]
          }
        }
      ]
    }