FHIR IG analytics| Package | hl7.fhir.us.davinci-pas |
| Resource Type | Bundle |
| Id | Bundle-ReferralAuthorizationResponseBundleExample.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "ReferralAuthorizationResponseBundleExample",
"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/PractitionerRequestorResponseExample",
"resource": {
"resourceType": "ClaimResponse",
"id": "PractitionerRequestorResponseExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse"
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClaimResponse_PractitionerRequestorResponseExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClaimResponse PractitionerRequestorResponseExample</b></p><a name=\"PractitionerRequestorResponseExample\"> </a><a name=\"hcPractitionerRequestorResponseExample\"> </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><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>: 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=\"PractitionerRole-ReferralPractitionerRoleExample.html\">PractitionerRole: telecom = ph: 4029993456</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>ItemPreAuthIssueDate</b>: 2005-05-02</p><p><b>ItemPreAuthPeriod</b>: 2005-05-02 --> 2005-06-02</p><blockquote><p><b>ItemAuthorizedProvider</b></p><ul><li>provider: <a href=\"Practitioner-ReferralPractitionerExample.html\">Practitioner SUSAN WATSON </a></li></ul></blockquote><blockquote><p><b>ItemAuthorizedDetail</b></p><ul><li>productOrServiceCode: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 3}\">Consultation</span></li><li>unitPrice: <span title=\"US Dollar\">$100.00</span> (USD)</li><li>quantity: 1</li></ul></blockquote><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>"
},
"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"
}
]
}
}
]
}
]
}
},
{
"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/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/Practitioner/ReferralPractitionerExample",
"resource": {
"resourceType": "Practitioner",
"id": "ReferralPractitionerExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner"
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Practitioner_ReferralPractitionerExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Practitioner ReferralPractitionerExample</b></p><a name=\"ReferralPractitionerExample\"> </a><a name=\"hcReferralPractitionerExample\"> </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-practitioner.html\">PAS Practitioner</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>name</b>: SUSAN WATSON </p></div>"
},
"identifier": [
{
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1234567893"
}
],
"name": [
{
"family": "WATSON",
"given": [
"SUSAN"
]
}
]
}
}
]
}