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

## Example Claim: Referral Authorization Example

Language: en

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

**LevelOfServiceCode**: Urgent

**identifier**: `urn:trnorg:9012345678`/111099

**status**: Active

**type**: Professional

**use**: Preauthorization

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

**created**: 2005-05-02 11:01:00+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-ReferralPractitionerRoleExample.md) |

### SupportingInfos

| | | | | |
| :--- | :--- | :--- | :--- | :--- |
| - | **Extension** | **Sequence** | **Category** | **Value[x]** |
| * |  | 1 | Additional Information | [DocumentReference: status = current; type = Physician procedure note; category = Clinical Note](DocumentReference-DocumentReferenceExample.md) |

### Diagnoses

| | | | |
| :--- | :--- | :--- | :--- |
| - | **Extension** | **Sequence** | **Diagnosis[x]** |
| * |  | 1 | Chronic pain syndrome |

### Insurances

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

> **item****ServiceItemRequestType**: Specialty Care Review**CertificationType**: Initial**ItemTraceNumber**: `http://example.org/ITEM_TRACE_NUMBER`/1122334**AuthorizationNumber**: 1122445**AdministrationReferenceNumber**: 9988311**RequestedService**: [ServiceRequest Consultation](ServiceRequest-ReferralRequestExample.md)**EPSDTIndicator**: false**NursingHomeResidentialStatus**: Newly Admitted**NursingHomeLevelOfCare**: Intermediate Care Facility (ICF)**RevenueUnitRateLimit**: 100**sequence**: 1**careTeamSequence**: 1**diagnosisSequence**: 1**category**: Consultation**productOrService**: Consultation**location**: Office



## Resource Content

```json
{
  "resourceType" : "Claim",
  "id" : "ReferralAuthorizationExample",
  "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" : "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"
          }
        ]
      }
    }
  ]
}

```
