FHIR IG analytics| Package | hl7.fhir.us.davinci-pas |
| Resource Type | Parameters |
| Id | Parameters-PASClaimInquiryOperationResponseExample.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Parameters",
"id": "PASClaimInquiryOperationResponseExample",
"language": "en",
"parameter": [
{
"name": "responseBundle",
"resource": {
"resourceType": "Bundle",
"id": "PASClaimInquiryResponseBundleExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle"
]
},
"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"
]
},
"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"
]
},
"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"
]
},
"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"
]
},
"identifier": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MB"
}
]
}
}
],
"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"
]
},
"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"
]
},
"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"
}
]
}
}
]
}
}
]
}
}
]
}