{ "resourceType": "Bundle", "id": "1", "meta": { "profile": [ "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-inquiry-response-bundle" ] }, "type": "collection", "timestamp": "2026-06-02T12:51:08.3051708+00:00", "entry": [ { "fullUrl": "http://example.org/fhir/ClaimResponse/1", "resource": { "resourceType": "ClaimResponse", "id": "1", "meta": { "profile": [ "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse" ] }, "identifier": [ { "system": "App.BaseUrl", "value": "1" }, { "system": "http://example.org/payer/PATIENT_EVENT_TRACE_NUMBER", "value": "1547380" }, { "type": { "coding": [ { "code": "CDR" } ] }, "value": "111099" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional", "display": "Professional" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/SubscriberExample" }, "created": "2026-06-02", "insurer": { "reference": "Organization/InsurerExample" }, "requestor": { "reference": "Organization/UMOExample" }, "request": { "reference": "Claim/MedicalServicesAuthorizationExample" }, "outcome": "complete", "preAuthRef": "100004513", "preAuthPeriod": { "start": "2019-09-22", "end": "2019-10-20" }, "item": [ { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2019-10-29" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "extension": [ { "url": "provider", "valueReference": { "reference": "Organization/UMOExample" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider" }, { "extension": [ { "url": "productOrServiceCode", "valueCodeableConcept": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "99204" } ], "text": "Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family." } }, { "url": "quantity", "valueQuantity": { "unit": "1" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R07.9", "display": "CHEST PAIN UNSPECIFIED" } ] } } ], "itemSequence": 1, "adjudication": [ { "extension": [ { "extension": [ { "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" } ] } } ] }, { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2019-10-29" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "extension": [ { "url": "provider", "valueReference": { "reference": "Organization/UMOExample" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider" }, { "extension": [ { "url": "productOrServiceCode", "valueCodeableConcept": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "93000" } ], "text": "Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report" } }, { "url": "quantity", "valueQuantity": { "unit": "1" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R07.9", "display": "CHEST PAIN UNSPECIFIED" } ] } } ], "itemSequence": 2, "adjudication": [ { "extension": [ { "extension": [ { "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" } ] } } ] }, { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2019-10-29" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "extension": [ { "url": "provider", "valueReference": { "reference": "Organization/UMOExample" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider" }, { "extension": [ { "url": "productOrServiceCode", "valueCodeableConcept": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "99205" } ], "text": "Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family." } }, { "url": "quantity", "valueQuantity": { "unit": "1" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R07.9", "display": "CHEST PAIN UNSPECIFIED" } ] } } ], "itemSequence": 3, "adjudication": [ { "extension": [ { "extension": [ { "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" } ] } } ] }, { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2019-10-29" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "extension": [ { "url": "provider", "valueReference": { "reference": "Organization/UMOExample" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider" }, { "extension": [ { "url": "productOrServiceCode", "valueCodeableConcept": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "93452" } ], "text": "Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed" } }, { "url": "quantity", "valueQuantity": { "unit": "1" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R07.9", "display": "CHEST PAIN UNSPECIFIED" } ] } } ], "itemSequence": 4, "adjudication": [ { "extension": [ { "extension": [ { "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" } ] } } ] }, { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2019-10-29" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "extension": [ { "url": "provider", "valueReference": { "reference": "Organization/UMOExample" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider" }, { "extension": [ { "url": "productOrServiceCode", "valueCodeableConcept": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "93454" } ], "text": "Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;" } }, { "url": "quantity", "valueQuantity": { "unit": "1" } } ], "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R07.9", "display": "CHEST PAIN UNSPECIFIED" } ] } } ], "itemSequence": 5, "adjudication": [ { "extension": [ { "extension": [ { "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" } ] } } ] } ], "adjudication": [ { "extension": [ { "extension": [ { "url": "number", "valueString": "100004513" }, { "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" } ] } } ], "communicationRequest": [ { "reference": "CommunicationRequest/1" } ] } }, { "fullUrl": "App.BaseUrl/CommunicationRequest/1", "resource": { "resourceType": "CommunicationRequest", "id": "1", "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R55.", "display": "SYNCOPE AND COLLAPSE" } ] } }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "R06.02", "display": "SHORTNESS OF BREATH" } ] } }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/diagnosis", "code": "I20.9", "display": "ANGINA PECTORIS UNSPECIFIED" } ] } } ], "status": "active" } }, { "fullUrl": "http://example.org/fhir/claim", "resource": { "resourceType": "Claim", "id": "MedicalServicesAuthorizationExample", "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService", "valueReference": { "reference": "ServiceRequest/ServiceRequest" } } ], "identifier": [ { "type": { "coding": [ { "code": "CDR" } ] }, "value": "111099" } ], "status": "active", "type": { "coding": [ { "code": "professional" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/SubscriberExample" }, "created": "2025", "insurer": { "reference": "Organization/InsurerExample" }, "provider": { "reference": "Organization/UMOExample" }, "priority": { "coding": [ { "code": "normal" } ] }, "careTeam": [ { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope", "valueBoolean": true } ], "sequence": 1, "provider": { "reference": "Practitioner/ReferralPractitionerExample" }, "role": { "coding": [ { "code": "QB", "display": "Purchase Service Provider" } ] }, "qualification": { "coding": [ { "code": "193200000X" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope", "valueBoolean": true } ], "sequence": 2, "provider": { "reference": "Organization/UMOExample" }, "role": { "coding": [ { "code": "FA", "display": "Facility" } ] }, "qualification": { "coding": [ { "code": "19320000X" } ] } } ], "supportingInfo": [ { "sequence": 1, "category": { "coding": [ { "code": "additionalInformation" } ] }, "valueAttachment": { "contentType": "application/pdf", "title": "myfile.pdf", "creation": "2025-03-30" } }, { "sequence": 2, "category": { "coding": [ { "code": "patientEvent" } ] }, "timingPeriod": { "start": "2026-03-05", "end": "2026-03-05" } }, { "sequence": 3, "category": { "coding": [ { "code": "additionalInformation" } ] }, "valueReference": { "reference": "DocumentReference/DocumentReference" } } ], "diagnosis": [ { "sequence": 1, "diagnosisCodeableConcept": { "coding": [ { "code": "A0104" } ] }, "type": [ { "coding": [ { "code": "ABF" } ] } ] }, { "sequence": 2, "diagnosisCodeableConcept": { "coding": [ { "code": "A0101" } ] }, "type": [ { "coding": [ { "code": "ABF" } ] } ] }, { "sequence": 3, "diagnosisCodeableConcept": { "coding": [ { "code": "A0102" } ] }, "type": [ { "coding": [ { "code": "ABF" } ] } ] }, { "sequence": 4, "diagnosisCodeableConcept": { "coding": [ { "code": "A0103" } ] }, "type": [ { "coding": [ { "code": "ABF" } ] } ] } ], "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "Coverage/InsuranceExample" } } ], "item": [ { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber", "valueString": "100004513" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "HS", "display": "Health Services Review" } ] } } ], "sequence": 1, "category": { "coding": [ { "code": "1" } ] }, "productOrService": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "99212" } ] }, "servicedPeriod": { "start": "2026-03-05", "end": "2026-03-05" }, "locationCodeableConcept": { "coding": [ { "system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set", "code": "22" } ] }, "quantity": { "value": 125, "unit": "UN" } } ] } }, { "fullUrl": "http://example.org/fhir/Organization/UMOExample", "resource": { "resourceType": "Organization", "id": "UMOExample", "identifier": [ { "type": { "coding": [ { "code": "NPI" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "1326085424" }, { "type": { "coding": [ { "code": "TIN" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "157892419" } ], "active": false, "name": "JFK MEDICAL CENTER", "address": [ { "line": [ "5301 S CONGRESS AVE" ], "city": "ATLANTIS", "state": "FL", "postalCode": "33462", "country": "US" } ], "contact": [ { "name": { "family": "LARSON" }, "telecom": [ { "system": "phone", "value": "5615482673" } ] } ] } }, { "fullUrl": "http://example.org/fhir/Organization/InsurerExample", "resource": { "resourceType": "Organization", "id": "InsurerExample", "identifier": [ { "type": { "coding": [ { "code": "NPI" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "1578924155" }, { "type": { "coding": [ { "code": "TIN" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "157892419" } ], "active": true, "type": [ { "coding": [ { "code": "professional" } ] } ], "name": "HUMANA" } }, { "fullUrl": "http://example.org/fhir/Coverage/InsuranceExample", "resource": { "resourceType": "Coverage", "id": "InsuranceExample", "status": "cancelled", "subscriberId": "8779034545", "beneficiary": { "reference": "Patient/SubscriberExample" }, "relationship": { "coding": [ { "code": "18" } ], "text": "Negative for Chlamydia Trachomatis rRNA" }, "period": { "start": "2025-03-27", "end": "2025-03-28" }, "payor": [ { "reference": "Organization/InsurerExample" } ] } }, { "fullUrl": "http://example.org/fhir/Patient/SubscriberExample", "resource": { "resourceType": "Patient", "id": "SubscriberExample", "identifier": [ { "type": { "coding": [ { "code": "MI" } ] }, "system": "http://example.org/MIN", "value": "H5026770000" } ], "name": [ { "family": "WATERIDGE", "given": [ "SUSBETH" ] } ], "gender": "male", "birthDate": "1948-11-15", "address": [ { "line": [ "9677 GREEN HILL ROAD" ], "city": "SHELBYVILLE", "state": "KY", "postalCode": "40065", "country": "US" } ] } }, { "fullUrl": "http://example.org/fhir/Practitioner/ReferralPractitionerExample", "resource": { "resourceType": "Practitioner", "id": "ReferralPractitionerExample", "identifier": [ { "type": { "coding": [ { "code": "NPI" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "1295852101" }, { "type": { "coding": [ { "code": "TIN" } ] }, "system": "http://hl7.org/fhir/sid/us-npi", "value": "157892419" } ], "name": [ { "family": "AARON", "given": [ "JOSHUA" ] } ], "telecom": [ { "system": "phone", "value": "8124248231" }, { "system": "fax", "value": "8124358794" } ], "address": [ { "line": [ "520 MARY ST STE 520" ], "city": "EVANSVILLE", "state": "IN", "postalCode": "47710", "country": "US" } ] } } ] }