FHIR IG analytics| Package | hl7.fhir.us.davinci-pas |
| Resource Type | Bundle |
| Id | Bundle-PASClaimInquiryResponseBundleExample.json |
| FHIR Version | R4 |
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No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "PASClaimInquiryResponseBundleExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"
]
},
"language": "en",
"identifier": {
"system": "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value": "5269367"
},
"type": "collection",
"timestamp": "2005-05-02T11:01:00+05:00",
"entry": [
{
"fullUrl": "http://example.org/fhir/ClaimResponse/PASClaimInquiryResponseExample",
"resource": {
"resourceType": "ClaimResponse",
"id": "PASClaimInquiryResponseExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse"
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_PASClaimInquiryResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PASClaimInquiryResponseExample</b></p><a name=\"PASClaimInquiryResponseExample\"> </a><a name=\"hcPASClaimInquiryResponseExample\"> </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-claiminquiryresponse.html\">PAS Claim Inquiry 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 ( http://example.org/MIN#12345678901)</a></p><p><b>created</b>: 2019-07-20 11:01:00+0500</p><p><b>insurer</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</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 --> 2005-06-02</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><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></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": "2019-07-20T11:01:00+05:00",
"insurer": {
"reference": "Organization/InsurerExample"
},
"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"
}
}
],
"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"
}
]
}
}
]
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/InsuranceExample"
}
}
]
}
},
{
"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/Coverage/InsuranceExample",
"resource": {
"resourceType": "Coverage",
"id": "InsuranceExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage"
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Coverage_InsuranceExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Coverage InsuranceExample</b></p><a name=\"InsuranceExample\"> </a><a name=\"hcInsuranceExample\"> </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-coverage.html\">PAS Coverage</a></p></div><p><b>status</b>: Active</p><p><b>subscriberId</b>: 1122334455</p><p><b>beneficiary</b>: <a href=\"Patient-SubscriberExample.html\">JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)</a></p><p><b>relationship</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/subscriber-relationship self}, {https://codesystem.x12.org/005010/1069 18}\">Self</span></p><p><b>payor</b>: <a href=\"Organization-InsurerExample.html\">Organization MARYLAND CAPITAL INSURANCE COMPANY</a></p></div>"
},
"status": "active",
"subscriberId": "1122334455",
"beneficiary": {
"reference": "Patient/SubscriberExample"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/subscriber-relationship",
"code": "self"
},
{
"system": "https://codesystem.x12.org/005010/1069",
"code": "18"
}
]
},
"payor": [
{
"reference": "Organization/InsurerExample"
}
]
}
},
{
"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 ( http://example.org/MIN#12345678901)</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": [
{
"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"
]
},
"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><blockquote><p><b>TransmissionIdentifiers</b></p><ul><li>applicationSenderCode: PROVIDERAPP</li><li>applicationReceiverCode: PAYERAPP</li><li>interchangeSenderID: PROVIDERID</li><li>interchangeReceiverID: PAYERID</li></ul></blockquote><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 ( http://example.org/MIN#12345678901)</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"
}
]
}
},
{
"extension": [
{
"url": "applicationSenderCode",
"valueString": "PROVIDERAPP"
},
{
"url": "applicationReceiverCode",
"valueString": "PAYERAPP"
},
{
"url": "interchangeSenderID",
"valueString": "PROVIDERID"
},
{
"url": "interchangeReceiverID",
"valueString": "PAYERID"
}
],
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers"
}
],
"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"
}
]
}
}
]
}
}
]
}