# Authorization Response with Practitioner Requestor Example - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-ballot

## Example ClaimResponse: Authorization Response with Practitioner Requestor Example

Language: en

Profile: [PAS Claim Response](StructureDefinition-profile-claimresponse.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**: 2005-05-02 11:02:00+0500

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

**requestor**: [PractitionerRole: telecom = ph: 4029993456](PractitionerRole-ReferralPractitionerRoleExample.md)

**request**: [Claim: extension = Urgent; identifier = urn:trnorg:9012345678#111099; status = active; type = Professional; use = preauthorization; created = 2005-05-02 11:01:00+0500; priority = Normal](Claim-ReferralAuthorizationExample.md)

**outcome**: Processing Complete

> **item****ItemRequestedServiceDate**: 2005-05-02 --> 2005-06-02**ItemPreAuthIssueDate**: 2005-05-02**ItemPreAuthPeriod**: 2005-05-02 --> 2005-06-02
> **ItemAuthorizedProvider**
* provider: [Practitioner SUSAN WATSON ](Practitioner-ReferralPractitionerExample.md)

> **ItemAuthorizedDetail**
* productOrServiceCode: Consultation
* unitPrice: $100.00 (USD)
* quantity: 1

**itemSequence**: 1

### Adjudications

| | | |
| :--- | :--- | :--- |
| - | **Extension** | **Category** |
| * |  | Submitted Amount |




## Resource Content

```json
{
  "resourceType" : "ClaimResponse",
  "id" : "PractitionerRequestorResponseExample",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
    ]
  },
  "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" : "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"
              }
            ]
          }
        }
      ]
    }
  ]
}

```
