FHIR IG analytics| Package | hl7.fhir.us.davinci-pas |
| Resource Type | Claim |
| Id | Claim-ReferralAuthorizationExample.json |
| FHIR Version | R4 |
No resources found
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Note: links and images are rebased to the (stated) source
Generated Narrative: Claim ReferralAuthorizationExample
Language: en
Profile: PAS Claim
LevelOfServiceCode: Urgent
TransmissionIdentifiers
- applicationSenderCode: PROVIDERAPP
- applicationReceiverCode: PAYERAPP
- interchangeSenderID: PROVIDERID
- interchangeReceiverID: PAYERID
identifier: urn:trnorg:9012345678/111099
status: Active
type: Professional
use: Preauthorization
patient: JOE SMITH Male, DoB Unknown ( http://example.org/MIN#12345678901)
created: 2005-05-02 11:01:00+0500
insurer: Organization MARYLAND CAPITAL INSURANCE COMPANY
provider: Organization DR. JOE SMITH CORPORATION
priority: Normal
| Extension | Sequence | Provider |
| 1 | PractitionerRole: telecom = ph: 4029993456 |
| Extension | Sequence | Category | Value[x] |
| 1 | Additional Information | DocumentReference: status = current; type = Physician procedure note; category = Clinical Note |
| Extension | Sequence | Diagnosis[x] |
| 1 | Chronic pain syndrome |
| Sequence | Focal | Coverage |
| 1 | true | Coverage: status = active; subscriberId = 1122334455; relationship = Self |
item
ServiceItemRequestType: Specialty Care Review
CertificationType: Initial
ItemTraceNumber:
http://example.org/ITEM_TRACE_NUMBER/1122334AuthorizationNumber: 1122445
AdministrationReferenceNumber: 9988311
RequestedService: ServiceRequest Consultation
EPSDTIndicator: false
NursingHomeResidentialStatus: Newly Admitted
NursingHomeLevelOfCare: Intermediate Care Facility (ICF)
RevenueUnitRateLimit: 100
sequence: 1
careTeamSequence: 1
diagnosisSequence: 1
category: Consultation
productOrService: Consultation
location: Office
FHIR
FHIRsmith{
"resourceType": "Claim",
"id": "ReferralAuthorizationExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim"
]
},
"language": "en",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"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"
}
]
}
}
]
}