FHIR IG analytics| Package | hl7.fhir.us.davinci-pas.r4 |
| Resource Type | Bundle |
| Id | Bundle-HomecareAuthorizationUpdateBundleExample.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Bundle",
"id": "HomecareAuthorizationUpdateBundleExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"
]
},
"identifier": {
"system": "http://example.org/SUBMITTER_TRANSACTION_IDENTIFIER",
"value": "A12345"
},
"type": "collection",
"timestamp": "2005-05-02T11:01:00+05:00",
"entry": [
{
"fullUrl": "http://example.org/fhir/Claim/HomecareAuthorizationUpdateExample",
"resource": {
"resourceType": "Claim",
"id": "HomecareAuthorizationUpdateExample",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update"
]
},
"text": {
"status": "extensions",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_HomecareAuthorizationUpdateExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim HomecareAuthorizationUpdateExample</b></p><a name=\"HomecareAuthorizationUpdateExample\"> </a><a name=\"hcHomecareAuthorizationUpdateExample\"> </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-update.html\">PAS Claim Update</a></p></div><p><b>identifier</b>: <code>http://example.org/PATIENT_EVENT_TRACE_NUMBER</code>/111099-UPDATE</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 ( Member Number)</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>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>Relateds</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Claim</b></td><td><b>Relationship</b></td></tr><tr><td style=\"display: none\">*</td><td><a href=\"Claim-HomecareAuthorizationExample.html\">Claim: extension = ; identifier = http://example.org/PATIENT_EVENT_TRACE_NUMBER#111099; status = active; type = Professional; use = preauthorization; created = 2019-07-20 11:01:00+0500; priority = Normal</a></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship prior}\">Prior Claim</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 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 42}\">Home Health Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}\">G0154</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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 3}\">Cancel</span></p><p><b>InfoCancelledFlag</b>: true</p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 42}\">Home Health Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}\">B4184</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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>InfoChanged</b>: added</p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 42}\">Home Health Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4185}\">B4185</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>"
},
"identifier": [
{
"system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value": "111099-UPDATE",
"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"
},
"provider": {
"reference": "Organization/UMOExample"
},
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal"
}
]
},
"related": [
{
"claim": {
"reference": "Claim/HomecareAuthorizationExample"
},
"relationship": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code": "prior"
}
]
}
}
],
"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": "HS",
"display": "Health Services 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"
}
]
}
}
],
"sequence": 1,
"category": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1365",
"code": "42",
"display": "Home Health Care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "G0154"
}
]
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "11"
}
]
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1525",
"code": "HS",
"display": "Health Services Review"
}
]
}
},
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1322",
"code": "3",
"display": "Cancel"
}
]
}
}
],
"modifierExtension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled",
"valueBoolean": true
}
],
"sequence": 2,
"category": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1365",
"code": "42",
"display": "Home Health Care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "B4184"
}
]
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "11"
}
]
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1525",
"code": "HS",
"display": "Health Services 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-infoChanged",
"valueCode": "added"
}
],
"sequence": 3,
"category": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1365",
"code": "42",
"display": "Home Health Care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "B4185"
}
]
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "11"
}
]
}
}
]
}
},
{
"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 ( Member Number)</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 ( Member Number)</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": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MB"
}
]
},
"system": "http://example.org/MIN",
"value": "12345678901"
}
],
"name": [
{
"family": "SMITH",
"given": [
"JOE"
]
}
],
"gender": "male"
}
},
{
"fullUrl": "http://example.org/fhir/Claim/HomecareAuthorizationExample",
"resource": {
"resourceType": "Claim",
"id": "HomecareAuthorizationExample",
"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_HomecareAuthorizationExample\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim HomecareAuthorizationExample</b></p><a name=\"HomecareAuthorizationExample\"> </a><a name=\"hcHomecareAuthorizationExample\"> </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><blockquote><p><b>HomeHealthCareInformation</b></p><ul><li>prognosis: <span title=\"Codes:{https://codesystem.x12.org/005010/923 1}\">1</span></li><li>date: 2005-05-02</li></ul></blockquote><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 ( Member Number)</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>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>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 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 42}\">Home Health Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets G0154}\">G0154</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><blockquote><p><b>item</b></p><p><b>ServiceItemRequestType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1525 HS}\">Health Services Review</span></p><p><b>CertificationType</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1322 I}\">Initial</span></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1365 42}\">Home Health Care</span></p><p><b>productOrService</b>: <span title=\"Codes:{http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets B4184}\">B4184</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": [
{
"extension": [
{
"url": "prognosis",
"valueCodeableConcept": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/923",
"code": "1"
}
]
}
},
{
"url": "date",
"valueDate": "2005-05-02"
}
],
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation"
}
],
"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"
},
"provider": {
"reference": "Organization/UMOExample"
},
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal"
}
]
},
"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": "HS",
"display": "Health Services 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"
}
]
}
}
],
"sequence": 1,
"category": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1365",
"code": "42",
"display": "Home Health Care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "G0154"
}
]
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "11"
}
]
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1525",
"code": "HS",
"display": "Health Services 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"
}
]
}
}
],
"sequence": 2,
"category": {
"coding": [
{
"system": "https://codesystem.x12.org/005010/1365",
"code": "42",
"display": "Home Health Care"
}
]
},
"productOrService": {
"coding": [
{
"system": "http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets",
"code": "B4184"
}
]
},
"locationCodeableConcept": {
"coding": [
{
"system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
"code": "11"
}
]
}
}
]
}
}
]
}