POST Create a claim submission request
POST /$submit
Creates a resource to generate a claim submission or claim inquiry request with prior authorization.
Parameters
Accept(header, string)
Allowed values:application/fhir+json.Access-Token(header, string, required) Salesforce org access token
Example:Bearer asvg473tebdjebdsakl!jsjndkcmldcmdcmedj3o9.asd.Instance-Domain-Name(header, string, required) Instance domain name of the salesforce org
Example:orgid.salesforce.com.
Request body
Media type: application/fhir+json. Schema: PASClaimRequestBundle (extended).
Contains a collection of resources.
- Rule: total only for search results or history.
- Rule: entry.search only for a search request.
- Rule: entry.request mandatory for batch, transaction, or history, else prohibited.
- Rule: entry.response mandatory for batch-response, transaction-response, or history, else prohibited.
- Rule: FullUrl must be unique in a bundle, or else entries with the same fullUrl must have different meta.versionId (except in history bundles).
- Rule: A document must have an identifier with a system and a value.
- Rule: A document must have a date.
- Rule: A document must have a Composition resource as the first resource.
- Rule: A message must have a MessageHeader resource as the first resource. Elements defined in Ancestors: id, meta, implicitRules, and language.
Includes all fields of PASClaimRequestBundle.
signature(Signature) Represents an electronic representation of a signature and its supporting context in a FHIR accessible form. The signature can be a cryptographic type (XML DigSig or a JWT), which is able to provide a non-repudiation proof, or a graphical image that represents a signature or a signature process.
Example
{
"resourceType": "Bundle",
"type": "collection",
"timestamp": "2005-05-02T11:01:00+05:00",
"entry": [
{
"resource": {
"resourceType": "Claim",
"id": "00001001",
"identifier": [
{
"system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value": "111099",
"assigner": {
"reference": "Organization/3"
}
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "professional"
}
]
},
"use": "preauthorization",
"patient": {
"reference": "Patient/1"
},
"created": "2019-07-20",
"insurer": {
"reference": "Organization/1"
},
"provider": {
"reference": "Organization/2"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType",
"valueCodeableConcept": {
"coding": [
{
"system": "http://codesystem.x12.org/005010/1525",
"code": "IN",
"display": "Initial Medical Services Reservation"
}
]
}
},
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType",
"valueCodeableConcept": {
"coding": [
{
"system": "http://codesystem.x12.org/005010/1322",
"code": "I",
"display": "Initial"
}
]
}
},
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber",
"valueString": "1122344"
},
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
"valueString": "33441122"
},
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference": {
"reference": "ServiceRequest/1"
}
}
],
"sequence": 1,
"productOrService": {
"coding": [
{
"system": "CPT",
"code": "39334",
"display": "Established Office Visit"
}
]
},
"servicedPeriod": {
"start": "2005-05-10",
"end": "2005-06-10"
},
"locationCodeableConcept": {
"coding": [
{
"system": "CPT1",
"code": "39334"
}
]
}
}
],
"priority": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/processpriority",
"code": "normal",
"display": "Normal"
}
]
},
"facility": {
"reference": "Location/1"
},
"careTeam": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope",
"valueBoolean": true
}
],
"sequence": 1,
"provider": {
"reference": "Practitioner/1"
}
}
],
"diagnosis": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate",
"valueDate": "2021-05-10"
}
],
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"system": "CPT",
"code": "39334"
}
]
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/1"
}
}
],
"supportingInfo": [
{
"sequence": 1,
"category": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
"code": "info",
"display": "Information"
}
]
},
"code": {
"coding": [
{
"system": "http://hl7.org/fhir/resource-types",
"code": "QuestionnaireResponse",
"display": "Questionnaire Response"
}
]
},
"valueReference": {
"reference": "QuestionnaireResponse/3141"
}
}
]
}
},
{
"resource": {
"resourceType": "QuestionnaireResponse",
"id": "home-o2-questionnaireresponse",
"questionnaire": "Questionnaire/0jNSG000000ByKD2A0",
"status": "completed",
"subject": {
"reference": "Patient/examplepatient",
"display": "Vlad"
},
"authored": "2023-08-21",
"item": [
{
"linkId": "1",
"text": "Patient Information",
"item": [
{
"linkId": "1.1",
"text": "Last Name but Different This Time",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "override"
},
{
"extension": [
{
"url": "role",
"valueCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/practitioner-role",
"code": "doctor",
"display": "Doctor"
}
]
}
},
{
"url": "practitioner",
"valueReference": {
"reference": "Practitioner/PractitionerExample",
"display": "Dr. Jane Doe"
}
}
],
"url": "author"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "Quinton"
}
]
},
{
"linkId": "1.2",
"text": "First Name",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "Vlad"
}
]
},
{
"linkId": "1.3",
"text": "Middle Initial",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "A, N"
}
]
},
{
"linkId": "1.4",
"text": "Date Of Birth",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueDate": "1956-12-01"
}
]
},
{
"linkId": "1.5",
"text": "Gender",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "male",
"display": "Male"
}
}
]
},
{
"linkId": "1.6",
"text": "Medicare ID",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "10A3D58WH22"
}
]
}
]
},
{
"linkId": "2",
"text": "Provider who is performing face-to-face evaluation",
"item": [
{
"linkId": "2.1",
"text": "Last Name",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "Doe"
}
]
},
{
"linkId": "2.2",
"text": "First Name",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "Jane"
}
]
},
{
"linkId": "2.3",
"text": "Middle Initial",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "B"
}
]
},
{
"linkId": "2.4",
"text": "NPI",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "1122334455"
}
]
},
{
"linkId": "2.5",
"text": "Date of Face-To-Face Evaluation",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "override"
},
{
"extension": [
{
"url": "role",
"valueCodeableConcept": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/practitioner-role",
"code": "doctor",
"display": "Doctor"
}
]
}
},
{
"url": "practitioner",
"valueReference": {
"reference": "Practitioner/PractitionerExample",
"display": "Dr. Jane Doe"
}
}
],
"url": "author"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueDate": "2019-07-18"
}
]
},
{
"linkId": "2.6",
"text": "Record",
"answer": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/containedReference",
"valueBoolean": false
}
],
"valueReference": {
"reference": "Patient/examplepatient",
"display": "Mr. Saul Moki"
}
}
]
}
]
},
{
"linkId": "3",
"text": "Coverage Requirements",
"item": [
{
"linkId": "3.1",
"text": "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "313296004",
"display": "Mild chronic obstructive pulmonary disease"
}
}
]
},
{
"linkId": "3.2",
"text": "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 95,
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"linkId": "3.3",
"text": "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 83,
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"linkId": "3.4",
"text": "Arterial oxygen saturation (Patient tested during exercise)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 95,
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"linkId": "3.5",
"text": "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 78,
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"linkId": "3.6",
"text": "Is there a documented improvement of hypoxemia during exercise with oxygen?",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueBoolean": true
}
]
}
]
},
{
"linkId": "4",
"text": "Prescribed Use",
"item": [
{
"linkId": "4.1",
"text": "Start date",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueDate": "2019-07-18"
}
]
},
{
"linkId": "4.2",
"text": "Length of need: (months) (99 = lifetime)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 99
}
}
]
},
{
"linkId": "4.3",
"text": "Peak Flow Rate",
"item": [
{
"linkId": "4.3.1",
"text": "LPM",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 2
}
}
]
},
{
"linkId": "4.3.2",
"text": "oxygen %",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 98
}
}
]
}
]
},
{
"linkId": "4.4",
"text": "Average Flow Rate",
"item": [
{
"linkId": "4.4.1",
"text": "LPM",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 2
}
}
]
},
{
"linkId": "4.4.2",
"text": "oxygen %",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueQuantity": {
"value": 97
}
}
]
}
]
},
{
"linkId": "4.5",
"text": "Frequency of use (choose all that apply)",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "At rest and awake"
}
]
}
]
},
{
"linkId": "5",
"text": "Oxygen Supply Order Details",
"item": [
{
"linkId": "5.1",
"text": "Current Order Description",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueString": "HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental"
}
]
},
{
"linkId": "5.1b",
"text": "Current Order Is For A Portable Device"
},
{
"linkId": "5.2",
"text": "Type",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueCoding": {
"system": "http://example.org",
"code": "122",
"display": "Compressed Gas"
}
}
]
},
{
"linkId": "5.3",
"text": "Means of oxygen delivery and accessories",
"answer": [
{
"extension": [
{
"extension": [
{
"url": "source",
"valueCode": "auto"
}
],
"url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
}
],
"valueCoding": {
"system": "http://example.org",
"code": "134",
"display": "Mask"
}
}
]
}
]
}
]
}
},
{
"resource": {
"resourceType": "Organization",
"id": "1",
"active": true,
"identifier": [
{
"use": "official",
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1100399991"
},
{
"use": "usual",
"system": "urn:oid:2.16.840.1.113883.2.4.6.1",
"value": "17-0112278"
}
],
"type": [
{
"coding": [
{
"system": "urn:oid:2.16.840.1.113883.2.4.15.1060",
"code": "V6",
"display": "University Medical Hospital"
},
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "prov",
"display": "Healthcare Provider"
}
]
}
],
"name": "Burgers University Medical Center",
"telecom": [
{
"system": "phone",
"value": "022-655 2300",
"use": "work"
}
],
"address": [
{
"use": "work",
"line": [
"Galapagosweg 91"
],
"city": "Den Burg",
"postalCode": "9105 PZ",
"country": "NLD"
},
{
"use": "work",
"line": [
"PO Box 2311"
],
"city": "Den Burg",
"postalCode": "9100 AA",
"country": "NLD"
}
],
"contact": [
{
"purpose": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code": "PRESS"
}
]
},
"telecom": [
{
"system": "phone",
"value": "022-655 2334"
}
]
},
{
"purpose": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code": "PATINF"
}
]
},
"telecom": [
{
"system": "phone",
"value": "022-655 2335"
}
]
}
]
}
},
{
"resource": {
"resourceType": "Organization",
"id": "2",
"active": true,
"identifier": [
{
"use": "official",
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1100399991"
},
{
"use": "usual",
"system": "urn:oid:2.16.840.1.113883.2.4.6.1",
"value": "17-0112278"
}
],
"type": [
{
"coding": [
{
"system": "urn:oid:2.16.840.1.113883.2.4.15.1060",
"code": "V6",
"display": "University Medical Hospital"
},
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "prov",
"display": "Healthcare Provider"
}
]
}
],
"name": "Burgers University Medical Center",
"telecom": [
{
"system": "phone",
"value": "022-655 2300",
"use": "work"
}
],
"address": [
{
"use": "work",
"line": [
"Galapagosweg 91"
],
"city": "Den Burg",
"postalCode": "9105 PZ",
"country": "NLD"
},
{
"use": "work",
"line": [
"PO Box 2311"
],
"city": "Den Burg",
"postalCode": "9100 AA",
"country": "NLD"
}
],
"contact": [
{
"purpose": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code": "PRESS"
}
]
},
"telecom": [
{
"system": "phone",
"value": "022-655 2334"
}
]
},
{
"purpose": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/contactentity-type",
"code": "PATINF"
}
]
},
"telecom": [
{
"system": "phone",
"value": "022-655 2335"
}
]
}
]
}
},
{
"resource": {
"resourceType": "Practitioner",
"id": "1",
"identifier": [
{
"use": "official",
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1100399991"
}
],
"active": true,
"name": [
{
"family": "Careful",
"given": [
"Adam"
],
"prefix": [
"Dr"
]
}
],
"address": [
{
"use": "home",
"line": [
"534 Erewhon St"
],
"city": "PleasantVille",
"state": "Vic",
"postalCode": "3999"
}
],
"qualification": [
{
"identifier": [
{
"system": "http://example.org/UniversityIdentifier",
"value": "12345"
}
],
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0360",
"code": "BS",
"display": "Bachelor of Science"
}
],
"text": "Bachelor of Science"
},
"period": {
"start": "1995"
},
"issuer": {
"display": "Example University"
}
}
]
}
},
{
"resource": {
"resourceType": "Coverage",
"id": "1",
"identifier": [
{
"system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER",
"value": "1640000003",
"assigner": {
"reference": "Organization/3"
}
}
],
"status": "active",
"beneficiary": {
"reference": "Patient/1"
},
"payor": [
{
"reference": "Organization/1"
}
]
}
},
{
"resource": {
"resourceType": "Patient",
"id": "1",
"identifier": [
{
"use": "usual",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MR"
}
]
},
"system": "urn:oid:1.2.36.146.595.217.0.1",
"value": "001RO0000045Ni3YAE",
"period": {
"start": "2001-05-06"
},
"assigner": {
"display": "Acme Healthcare"
}
}
],
"active": true,
"name": [
{
"use": "official",
"family": "Mychart",
"given": [
"Theodore"
]
}
],
"telecom": [
{
"use": "home"
},
{
"system": "phone",
"value": "(03) 5555 6473",
"use": "work",
"rank": 1
},
{
"system": "phone",
"value": "(03) 3410 5613",
"use": "mobile",
"rank": 2
},
{
"system": "phone",
"value": "(03) 5555 8834",
"use": "old",
"period": {
"end": "2014"
}
}
],
"gender": "male",
"birthDate": "1948-07-07",
"_birthDate": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/patient-birthTime",
"valueDateTime": "1974-12-25T14:35:45-05:00"
}
]
},
"deceasedBoolean": false,
"address": [
{
"use": "home",
"type": "both",
"text": "534 Erewhon St PeasantVille, Rainbow, Vic 3999",
"line": [
"534 Erewhon St"
],
"city": "PleasantVille",
"district": "Rainbow",
"state": "Vic",
"postalCode": "3999",
"period": {
"start": "1974-12-25"
}
}
],
"contact": [
{
"relationship": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0131",
"code": "N"
}
]
}
],
"name": {
"family": "du Marché",
"_family": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/humanname-own-prefix",
"valueString": "VV"
}
]
},
"given": [
"Bénédicte"
]
},
"telecom": [
{
"system": "phone",
"value": "+33 (237) 998327"
}
],
"address": {
"use": "home",
"type": "both",
"line": [
"534 Erewhon St"
],
"city": "PleasantVille",
"district": "Rainbow",
"state": "Vic",
"postalCode": "3999",
"period": {
"start": "1974-12-25"
}
},
"gender": "female",
"period": {
"start": "2012"
}
}
],
"managingOrganization": {
"reference": "Organization/1"
},
"generalPractitioner": [
{
"reference": "Practitioner/1"
}
]
}
},
{
"resource": {
"resourceType": "Location",
"id": "1",
"identifier": [
{
"use": "official",
"system": "http://hl7.org/fhir/sid/us-npi",
"value": "1100399991"
}
],
"status": "active",
"name": "South Wing, second floor",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "RNEU",
"display": "Neuroradiology unit"
}
]
},
"alias": [
"BU MC, SW, F2",
"Burgers University Medical Center, South Wing, second floor"
],
"description": "Second floor of the Old South Wing, formerly in use by Psychiatry",
"mode": "instance",
"telecom": [
{
"system": "phone",
"value": "2328",
"use": "work"
},
{
"system": "fax",
"value": "2329",
"use": "work"
},
{
"system": "email",
"value": "second wing admissions"
},
{
"system": "url",
"value": "http://sampleorg.com/southwing",
"use": "work"
}
],
"address": {
"use": "work",
"line": [
"Galapagosweg 91, Building A"
],
"city": "Den Burg",
"postalCode": "9105 PZ",
"country": "NLD"
},
"physicalType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/location-physical-type",
"code": "wi",
"display": "Wing"
}
]
},
"position": {
"longitude": -83.6945691,
"latitude": 42.25475478,
"altitude": 0
},
"managingOrganization": {
"reference": "Organization/1"
},
"endpoint": [
{
"reference": "Endpoint/1"
}
]
}
},
{
"resource": {
"resourceType": "ServiceRequest",
"id": "1",
"status": "active",
"intent": "order",
"authoredOn": "2015-02-07T13:28:17-05:00",
"code": {
"coding": [
{
"system": "http://codesystem.x12.org/005010/1365",
"code": "3",
"display": "Consultation"
}
]
},
"quantityQuantity": {
"value": 1,
"system": "http://unitsofmeasure.org",
"code": "{visit}"
},
"subject": {
"reference": "Patient/SubscriberExample"
}
}
}
]
}Responses
- 201
No match was found. Resource created.
Headers:
Location(string, required)
Example:http://xxx/\\$PriorAuthClaim.
Media type:
application/fhir+json. Schema:PASClaimResponseBundle (extended).Contains a collection of resources.
- Rule: total only for search results or history.
- Rule: entry.search only for a search request.
- Rule: entry.request mandatory for batch, transaction, or history, else prohibited.
- Rule: entry.response mandatory for batch-response, transaction-response, or history, else prohibited.
- Rule: FullUrl must be unique in a bundle, or else entries with the same fullUrl must have different meta.versionId (except in history bundles).
- Rule: A document must have an identifier with a system and a value.
- Rule: A document must have a date.
- Rule: A document must have a Composition resource as the first resource.
- Rule: A message must have a MessageHeader resource as the first resource. Elements defined in Ancestors: id, meta, implicitRules, and language.
Includes all fields of
PASClaimResponseBundle.signature(Signature) Represents an electronic representation of a signature and its supporting context in a FHIR accessible form. The signature can be a cryptographic type (XML DigSig or a JWT), which is able to provide a non-repudiation proof, or a graphical image that represents a signature or a signature process.
Example
{ "resourceType": "Bundle", "type": "collection", "id": "PASClaimResponseExample", "meta": { "profile": [ "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse" ] }, "timestamp": "2005-05-02T11:02:00+05:00", "entry": [ { "resource": { "resourceType": "ClaimResponse", "id": "1", "identifier": [ { "system": "http://example.org/REVIEW_IDENTIFICATION_NUMBER", "value": "AUTH0001" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/1" }, "created": "2019-07-20", "insurer": { "reference": "Organization/1" }, "outcome": "complete", "request": { "reference": "PASClaim/1" }, "insurance": [ { "sequence": 1, "focal": true, "coverage": { "reference": "Coverage/1" } } ], "item": [ { "id": "123", "extension": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate", "valuePeriod": { "start": "2005-05-02", "end": "2005-06-02" } }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction", "valueCode": "A1" }, { "reviewActionReason": [ { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason", "valueCode": "A2" } ] }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate", "valueDate": "2005-05-02" } ], "itemSequence": 1, "adjudication": [ { "id": "12", "reason": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication-reason", "code": "ar001", "display": "Not covered" } ] }, "category": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication", "code": "submitted" } ] } } ] } ], "addItem": [ { "id": "123", "productOrService": { "coding": [ { "system": "http://www.ama-assn.org/go/cpt", "code": "99212", "display": "Established Office Visit" } ] }, "adjudication": [ { "extension": [ { "extension": [ { "url": "number", "valueString": "AUTH0001" }, { "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode", "valueCodeableConcept": { "coding": [ { "system": "http://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" } ] } } ], "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/ex-USCLS", "code": "2141", "display": "Radiograph, bitewing" } ], "text": "Product Or Service" } } ], "processNote": [ { "text": "sample Note explanatory text for the claim submitted" } ] } }, { "resource": { "resourceType": "QuestionnaireResponse", "id": "home-o2-questionnaireresponse", "questionnaire": "Questionnaire/0jNSG000000ByKD2A0", "status": "completed", "subject": { "reference": "Patient/examplepatient", "display": "Vlad" }, "authored": "2023-08-21", "item": [ { "linkId": "1", "text": "Patient Information", "item": [ { "linkId": "1.1", "text": "Last Name but Different This Time", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "override" }, { "extension": [ { "url": "role", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/practitioner-role", "code": "doctor", "display": "Doctor" } ] } }, { "url": "practitioner", "valueReference": { "reference": "Practitioner/PractitionerExample", "display": "Dr. Jane Doe" } } ], "url": "author" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "Quinton" } ] }, { "linkId": "1.2", "text": "First Name", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "Vlad" } ] }, { "linkId": "1.3", "text": "Middle Initial", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "A, N" } ] }, { "linkId": "1.4", "text": "Date Of Birth", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueDate": "1956-12-01" } ] }, { "linkId": "1.5", "text": "Gender", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "male", "display": "Male" } } ] }, { "linkId": "1.6", "text": "Medicare ID", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "10A3D58WH22" } ] } ] }, { "linkId": "2", "text": "Provider who is performing face-to-face evaluation", "item": [ { "linkId": "2.1", "text": "Last Name", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "Doe" } ] }, { "linkId": "2.2", "text": "First Name", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "Jane" } ] }, { "linkId": "2.3", "text": "Middle Initial", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "B" } ] }, { "linkId": "2.4", "text": "NPI", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "1122334455" } ] }, { "linkId": "2.5", "text": "Date of Face-To-Face Evaluation", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "override" }, { "extension": [ { "url": "role", "valueCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/practitioner-role", "code": "doctor", "display": "Doctor" } ] } }, { "url": "practitioner", "valueReference": { "reference": "Practitioner/PractitionerExample", "display": "Dr. Jane Doe" } } ], "url": "author" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueDate": "2019-07-18" } ] }, { "linkId": "2.6", "text": "Record", "answer": [ { "extension": [ { "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/containedReference", "valueBoolean": false } ], "valueReference": { "reference": "Patient/examplepatient", "display": "Mr. Saul Moki" } } ] } ] }, { "linkId": "3", "text": "Coverage Requirements", "item": [ { "linkId": "3.1", "text": "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueCoding": { "system": "http://snomed.info/sct", "code": "313296004", "display": "Mild chronic obstructive pulmonary disease" } } ] }, { "linkId": "3.2", "text": "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 95, "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "3.3", "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 83, "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "3.4", "text": "Arterial oxygen saturation (Patient tested during exercise)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 95, "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "3.5", "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 78, "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "3.6", "text": "Is there a documented improvement of hypoxemia during exercise with oxygen?", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueBoolean": true } ] } ] }, { "linkId": "4", "text": "Prescribed Use", "item": [ { "linkId": "4.1", "text": "Start date", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueDate": "2019-07-18" } ] }, { "linkId": "4.2", "text": "Length of need: (months) (99 = lifetime)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 99 } } ] }, { "linkId": "4.3", "text": "Peak Flow Rate", "item": [ { "linkId": "4.3.1", "text": "LPM", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 2 } } ] }, { "linkId": "4.3.2", "text": "oxygen %", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 98 } } ] } ] }, { "linkId": "4.4", "text": "Average Flow Rate", "item": [ { "linkId": "4.4.1", "text": "LPM", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 2 } } ] }, { "linkId": "4.4.2", "text": "oxygen %", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueQuantity": { "value": 97 } } ] } ] }, { "linkId": "4.5", "text": "Frequency of use (choose all that apply)", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "At rest and awake" } ] } ] }, { "linkId": "5", "text": "Oxygen Supply Order Details", "item": [ { "linkId": "5.1", "text": "Current Order Description", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueString": "HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental" } ] }, { "linkId": "5.1b", "text": "Current Order Is For A Portable Device" }, { "linkId": "5.2", "text": "Type", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueCoding": { "system": "http://example.org", "code": "122", "display": "Compressed Gas" } } ] }, { "linkId": "5.3", "text": "Means of oxygen delivery and accessories", "answer": [ { "extension": [ { "extension": [ { "url": "source", "valueCode": "auto" } ], "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" } ], "valueCoding": { "system": "http://example.org", "code": "134", "display": "Mask" } } ] } ] } ] } }, { "resource": { "resourceType": "Organization", "id": "1", "identifier": [ { "use": "official", "system": "urn:oid:2.16.528.1", "value": "91654" }, { "use": "usual", "system": "urn:oid:2.16.840.1.113883.2.4.6.1", "value": "17-0112278" } ], "type": [ { "coding": [ { "system": "urn:oid:2.16.840.1.113883.2.4.15.1060", "code": "V6", "display": "University Medical Hospital" }, { "system": "http://terminology.hl7.org/CodeSystem/organization-type", "code": "prov", "display": "Healthcare Provider" } ] } ], "name": "Burgers University Medical Center", "active": true, "telecom": [ { "system": "phone", "value": "022-655 2300", "use": "work" } ], "address": [ { "use": "work", "line": [ "Galapagosweg 91" ], "city": "Den Burg", "postalCode": "9105 PZ", "country": "NLD" }, { "use": "work", "line": [ "PO Box 2311" ], "city": "Den Burg", "postalCode": "9100 AA", "country": "NLD" } ], "contact": [ { "purpose": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/contactentity-type", "code": "PRESS" } ] }, "telecom": [ { "system": "phone", "value": "022-655 2334" } ] }, { "purpose": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/contactentity-type", "code": "PATINF" } ] }, "telecom": [ { "system": "phone", "value": "022-655 2335" } ] } ] } }, { "resource": { "resourceType": "Practitioner", "id": "1", "identifier": [ { "system": "http://www.acme.org/practitioners", "value": "23" } ], "active": true, "name": [ { "family": "Careful", "given": [ "Adam" ], "prefix": [ "Dr" ] } ], "address": [ { "use": "home", "line": [ "534 Erewhon St" ], "city": "PleasantVille", "state": "Vic", "postalCode": "3999" } ], "qualification": [ { "identifier": [ { "system": "http://example.org/UniversityIdentifier", "value": "12345" } ], "code": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0360", "code": "BS", "display": "Bachelor of Science" } ], "text": "Bachelor of Science" }, "period": { "start": "1995" }, "issuer": { "display": "Example University" } } ] } }, { "resource": { "resourceType": "Coverage", "id": "1", "status": "active", "beneficiary": { "reference": "Patient/1" }, "payor": [ { "reference": "Organization/1" } ] } }, { "resource": { "resourceType": "Patient", "id": "1", "identifier": [ { "use": "usual", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "MR" } ] }, "system": "urn:oid:1.2.36.146.595.217.0.1", "value": "12345", "period": { "start": "2001-05-06" }, "assigner": { "display": "Acme Healthcare" } } ], "active": true, "name": [ { "use": "official", "family": "Chalmers", "given": [ "Peter", "James" ] }, { "use": "usual", "family": "Rings", "given": [ "Jim" ] }, { "use": "maiden", "family": "Windsor", "given": [ "Peter", "James" ], "period": { "end": "2002" } } ], "telecom": [ { "use": "home" }, { "system": "phone", "value": "(03) 5555 6473", "use": "work", "rank": 1 }, { "system": "phone", "value": "(03) 3410 5613", "use": "mobile", "rank": 2 }, { "system": "phone", "value": "(03) 5555 8834", "use": "old", "period": { "end": "2014" } } ], "gender": "male", "birthDate": "1974-12-25", "_birthDate": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/patient-birthTime", "valueDateTime": "1974-12-25T14:35:45-05:00" } ] }, "deceasedBoolean": false, "address": [ { "use": "home", "type": "both", "text": "534 Erewhon St PeasantVille, Rainbow, Vic 3999", "line": [ "534 Erewhon St" ], "city": "PleasantVille", "district": "Rainbow", "state": "Vic", "postalCode": "3999", "period": { "start": "1974-12-25" } } ], "contact": [ { "relationship": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0131", "code": "N" } ] } ], "name": { "family": "du Marché", "_family": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/humanname-own-prefix", "valueString": "VV" } ] }, "given": [ "Bénédicte" ] }, "telecom": [ { "system": "phone", "value": "+33 (237) 998327" } ], "address": { "use": "home", "type": "both", "line": [ "534 Erewhon St" ], "city": "PleasantVille", "district": "Rainbow", "state": "Vic", "postalCode": "3999", "period": { "start": "1974-12-25" } }, "gender": "female", "period": { "start": "2012" } } ], "managingOrganization": { "reference": "Organization/1" }, "generalPractitioner": [ { "reference": "Practitioner/1" } ] } } ] } - 500
Media type:
application/fhir+json. Schema:OperationOutcome.Example
{ "resourceType": "OperationOutcome", "issue": [ { "severity": "error", "code": "exception", "details": { "text": "An unexpected error occured while submitting the claim. Failed for \"label\"" } } ] } - 400
Media type:
application/fhir+json. Schema:any.Type:
any.Example
{ "resourceType": "Bundle", "type": "collection", "id": "PASClaimErrorExample", "timestamp": "2005-05-02T11:02:00+05:00", "entry": [ { "resource": { "resourceType": "ClaimResponse", "id": "1", "identifier": [ { "system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER", "value": "111099" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/1" }, "created": "2005-05-02T11:02:00+05:00", "insurer": { "reference": "Organization/1" }, "outcome": "error", "error": [ { "code": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication-error", "code": "a001", "display": "Missing Identifier" }, { "display": "Missing Practitioner" }, { "display": "Given Facility not found" } ] } } ] } } ] } - 404
Media type:
application/fhir+json. Schema:any.Type:
any.Example
{ "resourceType": "Bundle", "type": "collection", "id": "PASClaimErrorExample", "timestamp": "2005-05-02T11:02:00+05:00", "entry": [ { "resource": { "resourceType": "ClaimResponse", "id": "1", "identifier": [ { "system": "http://example.org/PATIENT_EVENT_TRACE_NUMBER", "value": "111099" } ], "status": "active", "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/claim-type", "code": "professional" } ] }, "use": "preauthorization", "patient": { "reference": "Patient/1" }, "created": "2005-05-02T11:02:00+05:00", "insurer": { "reference": "Organization/1" }, "outcome": "error", "error": [ { "code": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/adjudication-error", "code": "a001", "display": "Missing Identifier" }, { "display": "Missing Practitioner" }, { "display": "Given Facility not found" } ] } } ] } } ] }