davinci_pas_test_kit 0.15.1 → 0.15.2

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Files changed (98) hide show
  1. checksums.yaml +4 -4
  2. data/config/presets/pas_client_example.json +2 -2
  3. data/config/presets/pas_client_v201_run_against_pas_server.json +2 -2
  4. data/config/presets/pas_client_v221_run_against_pas_server.json +3 -3
  5. data/config/presets/pas_ri.json +6 -6
  6. data/config/presets/pas_server_v201_run_against_pas_client.json.erb +6 -6
  7. data/config/presets/pas_server_v221_run_against_pas_client.json.erb +10 -10
  8. data/lib/davinci_pas_test_kit/client/abstract_gather_must_support_test.rb +2 -48
  9. data/lib/davinci_pas_test_kit/client/client_input_descriptions.rb +29 -0
  10. data/lib/davinci_pas_test_kit/client/endpoints/claim_endpoint.rb +25 -9
  11. data/lib/davinci_pas_test_kit/client/user_input_response.rb +25 -6
  12. data/lib/davinci_pas_test_kit/client/v2.0.1/client_suite.rb +1 -1
  13. data/lib/davinci_pas_test_kit/client/v2.2.1/client_suite.rb +1 -1
  14. data/lib/davinci_pas_test_kit/cross_suite/fhirpath_utils.rb +13 -3
  15. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/beneficiary/metadata.yml +4 -0
  16. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/claim_inquiry/metadata.yml +15 -0
  17. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/claim_update/metadata.yml +17 -0
  18. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/claiminquiryresponse/metadata.yml +15 -0
  19. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/claimresponse/metadata.yml +15 -0
  20. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/communication_request/metadata.yml +4 -0
  21. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/coverage/metadata.yml +1 -0
  22. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/device_request/metadata.yml +2 -0
  23. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/encounter/metadata.yml +3 -0
  24. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/insurer/metadata.yml +1 -0
  25. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/medication_request/metadata.yml +2 -0
  26. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/metadata.yml +143 -0
  27. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/nutrition_order/metadata.yml +2 -0
  28. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/pas_inquiry_request_bundle/metadata.yml +2 -0
  29. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/pas_inquiry_response_bundle/metadata.yml +2 -0
  30. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/pas_request_bundle/metadata.yml +2 -0
  31. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/pas_response_bundle/metadata.yml +2 -0
  32. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/practitioner/metadata.yml +1 -0
  33. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/practitioner_role/metadata.yml +1 -0
  34. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/requestor/metadata.yml +1 -0
  35. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/service_request/metadata.yml +3 -0
  36. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/subscriber/metadata.yml +4 -0
  37. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.0.1/task/metadata.yml +1 -0
  38. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/beneficiary/metadata.yml +1 -0
  39. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/claim_inquiry/metadata.yml +23 -0
  40. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/claim_update/metadata.yml +31 -0
  41. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/claiminquiryresponse/metadata.yml +42 -0
  42. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/claimresponse/metadata.yml +42 -0
  43. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/communication_request/metadata.yml +4 -0
  44. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/coverage/metadata.yml +1 -0
  45. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/device_request/metadata.yml +2 -0
  46. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/encounter/metadata.yml +3 -0
  47. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/insurer/metadata.yml +1 -0
  48. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/medication_request/metadata.yml +2 -0
  49. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/metadata.yml +265 -0
  50. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/nutrition_order/metadata.yml +2 -0
  51. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/pas_inquiry_request_bundle/metadata.yml +2 -0
  52. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/pas_inquiry_response_bundle/metadata.yml +2 -0
  53. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/pas_request_bundle/metadata.yml +2 -0
  54. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/pas_response_bundle/metadata.yml +2 -0
  55. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/practitioner/metadata.yml +1 -0
  56. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/practitioner_role/metadata.yml +1 -0
  57. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/requestor/metadata.yml +1 -0
  58. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/service_request/metadata.yml +3 -0
  59. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/subscriber/metadata.yml +1 -0
  60. data/lib/davinci_pas_test_kit/cross_suite/generated/v2.2.1/task/metadata.yml +4 -0
  61. data/lib/davinci_pas_test_kit/cross_suite/pas_bundle_validation.rb +97 -39
  62. data/lib/davinci_pas_test_kit/cross_suite/pas_constants.rb +6 -0
  63. data/lib/davinci_pas_test_kit/cross_suite/pas_datatype_constraints.rb +166 -0
  64. data/lib/davinci_pas_test_kit/cross_suite/response_selection_utils.rb +26 -10
  65. data/lib/davinci_pas_test_kit/cross_suite/validator_suppressions.rb +206 -146
  66. data/lib/davinci_pas_test_kit/docs/demo/PAS Client Suite Demonstration.postman_collection.json +4 -4
  67. data/lib/davinci_pas_test_kit/generator/must_support_test_generator.rb +6 -0
  68. data/lib/davinci_pas_test_kit/generator/pas_must_support_metadata_extractor.rb +1 -2
  69. data/lib/davinci_pas_test_kit/generator/server_must_support_group_generator.rb +23 -0
  70. data/lib/davinci_pas_test_kit/generator/server_suite_generator.rb +6 -0
  71. data/lib/davinci_pas_test_kit/generator/templates/must_support.rb.erb +3 -2
  72. data/lib/davinci_pas_test_kit/generator/templates/server_must_support_group.rb.erb +22 -0
  73. data/lib/davinci_pas_test_kit/generator/templates/server_suite.rb.erb +4 -5
  74. data/lib/davinci_pas_test_kit/generator/templates/use_case_group.rb.erb +3 -0
  75. data/lib/davinci_pas_test_kit/generator/use_case_group_generator.rb +14 -8
  76. data/lib/davinci_pas_test_kit/requirements/generated/davinci_pas_server_suite_v221_requirements_coverage.csv +28 -28
  77. data/lib/davinci_pas_test_kit/server/generated/v2.0.1/pas_server_approval_use_case_group.rb +1 -0
  78. data/lib/davinci_pas_test_kit/server/generated/v2.0.1/pas_server_denial_use_case_group.rb +1 -0
  79. data/lib/davinci_pas_test_kit/server/generated/v2.0.1/pas_server_pended_use_case_group.rb +1 -0
  80. data/lib/davinci_pas_test_kit/server/generated/v2.0.1/server_suite.rb +4 -5
  81. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/claiminquiryresponse/server_inquire_response_must_support_claiminquiryresponse_test.rb +2 -0
  82. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/claimresponse/server_submit_response_must_support_claimresponse_test.rb +2 -0
  83. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/pas_server_approval_use_case_group.rb +2 -0
  84. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/pas_server_denial_use_case_group.rb +2 -0
  85. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/pas_server_must_support_group.rb +12 -0
  86. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/pas_server_pended_use_case_group.rb +5 -0
  87. data/lib/davinci_pas_test_kit/server/generated/v2.2.1/server_suite.rb +4 -5
  88. data/lib/davinci_pas_test_kit/server/server_response_bundle_validation_test.rb +14 -5
  89. data/lib/davinci_pas_test_kit/server/v2.2.1/claim_inquiry/server_claim_inquiry_response_tests.rb +89 -0
  90. data/lib/davinci_pas_test_kit/server/v2.2.1/pas_error_group.rb +2 -0
  91. data/lib/davinci_pas_test_kit/server/v2.2.1/pas_server_claim_inquiry_responses_group.rb +17 -0
  92. data/lib/davinci_pas_test_kit/server/v2.2.1/pas_server_no_custom_extensions_test.rb +241 -0
  93. data/lib/davinci_pas_test_kit/server/v2.2.1/pas_server_subscription_capability_statement_test.rb +40 -0
  94. data/lib/davinci_pas_test_kit/server/v2.2.1/pas_server_subscription_setup.rb +14 -9
  95. data/lib/davinci_pas_test_kit/server/v2.2.1/server_replaced_pa_inquire_reference_input_test.rb +63 -0
  96. data/lib/davinci_pas_test_kit/server/v2.2.1/server_replaced_pa_inquire_reference_test.rb +109 -0
  97. data/lib/davinci_pas_test_kit/version.rb +2 -2
  98. metadata +9 -2
data/config/presets/pas_server_v221_run_against_pas_client.json.erb CHANGED
@@ -30,7 +30,7 @@
30
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  "optional": true,
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  "title": "PAS Submit Request Payload for Approval Response",
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  "type": "textarea",
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- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ReferralAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
33
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ReferralAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": 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\"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": 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],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1,\n \"unit\": \"visit\"\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": 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\"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"admissionDates\",\n \"display\": \"Admission Dates\"\n }\n ]\n },\n \"sequence\": 4,\n \"timingPeriod\": {\n \"start\": \"2021-09-10\",\n \"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingDate\": \"2021-09-13\"\n },\n {\n \"sequence\": 99,\n \"category\": {\n \"coding\": [\n {\n \"system\": \"urn:inferno:pas-codes\",\n \"code\": \"default-profile-testing\",\n \"display\": \"Testing Profile Defaulting\"\n }\n ]\n },\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"4\",\n \"display\": \"Diagnostic\"\n }\n ]\n }\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"https://codesystem.x12.org/005010/673\",\n \"code\": \"VS\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
34
34
  },
35
35
  {
36
36
  "name": "denial_pa_submit_request_payload",
@@ -38,7 +38,7 @@
38
38
  "optional": true,
39
39
  "title": "PAS Submit Request Payload for Denial Response",
40
40
  "type": "textarea",
41
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ReferralAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": 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\"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": 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\"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": 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\"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly 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],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"Prior authorization inquiry details provided\"\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientEvent\",\n \"display\": \"Patient Event\"\n }\n ]\n },\n \"sequence\": 3,\n \"timingPeriod\": {\n \"start\": \"2021-09-01\",\n \"end\": \"2021-09-03\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": 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{\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"4\",\n \"display\": \"Diagnostic\"\n }\n ]\n }\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"http://unitsofmeasure.org\",\n \"code\": \"1\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
41
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ReferralAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
42
42
  },
43
43
  {
44
44
  "name": "pended_pa_submit_request_payload",
@@ -46,7 +46,7 @@
46
46
  "optional": true,
47
47
  "title": "PAS Submit Request Payload for Pended Response",
48
48
  "type": "textarea",
49
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"DeviceAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/DeviceRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/DeviceRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ],\n \"servicedPeriod\": {\n \"start\": \"2016-08-10\",\n \"end\": \"2016-08-12\"\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"Prior authorization inquiry details provided\"\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientEvent\",\n \"display\": \"Patient Event\"\n }\n ]\n },\n \"sequence\": 3,\n \"timingPeriod\": {\n \"start\": \"2021-09-01\",\n \"end\": \"2021-09-03\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"admissionDates\",\n \"display\": \"Admission Dates\"\n }\n ]\n },\n \"sequence\": 4,\n \"timingPeriod\": {\n \"start\": \"2021-09-10\",\n \"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingDate\": \"2021-09-13\"\n },\n {\n \"sequence\": 99,\n \"category\": {\n \"coding\": [\n {\n \"system\": \"urn:inferno:pas-codes\",\n \"code\": \"default-profile-testing\",\n \"display\": \"Testing Profile Defaulting\"\n }\n ]\n },\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DeviceRequest/DeviceRequestExample\",\n \"resource\": {\n \"resourceType\": \"DeviceRequest\",\n \"id\": \"DeviceRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-devicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"codeCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E1223\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"authoredOn\": \"2005-06-02\",\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"requester\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
49
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"DeviceAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DeviceRequest/DeviceRequestExample\",\n \"resource\": {\n \"resourceType\": \"DeviceRequest\",\n \"id\": \"DeviceRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-devicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"codeCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E1223\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"authoredOn\": \"2005-06-02\",\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"requester\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"display\": \"Surgical encounter reason\"\n }\n ]\n }\n }\n ]\n}"
50
50
  },
51
51
  {
52
52
  "name": "pended_pa_inquire_request_payload",
@@ -54,7 +54,7 @@
54
54
  "optional": true,
55
55
  "title": "PAS Inquire Request Payload",
56
56
  "type": "textarea",
57
- "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"PASBundleInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PASClaimInquiryExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PASClaimInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"traceNumber\",\n \"valueString\": \"TRN-12345\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1325\",\n \"code\": \"AA\",\n \"display\": \"Authorized\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/service-type\",\n \"code\": \"1\",\n \"display\": \"Adoption/Permanent Care Info/Support\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"billablePeriod\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"quantity\": {\n \"value\": 1\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0154\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"B4185\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n }\n ],\n \"sequence\": 3,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"quantity\": {\n \"value\": 1\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0154\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ],\n \"servicedPeriod\": {\n \"start\": \"2016-08-10\",\n \"end\": \"2016-08-12\"\n }\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"Claim/PreviousAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"type\",\n \"valueString\": \"summary\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"Prior authorization inquiry details provided\"\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientEvent\",\n \"display\": \"Patient Event\"\n }\n ]\n },\n \"sequence\": 3,\n \"timingPeriod\": {\n \"start\": \"2021-09-01\",\n \"end\": \"2021-09-03\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"admissionDates\",\n \"display\": \"Admission Dates\"\n }\n ]\n },\n \"sequence\": 4,\n \"timingPeriod\": {\n \"start\": \"2021-09-10\",\n \"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingPeriod\": {\n \"start\": \"2021-09-13\",\n \"end\": \"2021-09-15\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"789312\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"reference\": \"Endpoint/ReferralEndpointExample\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"987654321\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n ]\n }\n]"
57
+ "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"PASBundleInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PASClaimInquiryExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PASClaimInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"traceNumber\",\n \"valueString\": \"TRN-12345\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1325\",\n \"code\": \"AA\",\n \"display\": \"Authorized\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/service-type\",\n \"code\": \"1\",\n \"display\": \"Adoption/Permanent Care Info/Support\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"billablePeriod\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"quantity\": {\n \"value\": 1,\n \"unit\": \"visit\"\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0154\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"B4185\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n }\n ],\n \"sequence\": 3,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"quantity\": {\n \"value\": 1,\n \"unit\": \"visit\"\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0154\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ],\n \"servicedPeriod\": {\n \"start\": \"2016-08-10\",\n \"end\": \"2016-08-12\"\n }\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"Claim/PreviousAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"type\",\n \"valueString\": \"summary\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"Prior authorization inquiry details provided\"\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientEvent\",\n \"display\": \"Patient Event\"\n }\n ]\n },\n \"sequence\": 3,\n \"timingPeriod\": {\n \"start\": \"2021-09-01\",\n \"end\": \"2021-09-03\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"admissionDates\",\n \"display\": \"Admission Dates\"\n }\n ]\n },\n \"sequence\": 4,\n \"timingPeriod\": {\n \"start\": \"2021-09-10\",\n \"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingPeriod\": {\n \"start\": \"2021-09-13\",\n \"end\": \"2021-09-15\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8383066098\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"reference\": \"Endpoint/ReferralEndpointExample\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"987654321\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n ]\n }\n]"
58
58
  },
59
59
  {
60
60
  "name": "must_support_pa_submit_request_payload",
@@ -62,7 +62,7 @@
62
62
  "optional": true,
63
63
  "title": "Additional PAS Submit Request Payloads",
64
64
  "type": "textarea",
65
- "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"DeviceAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/DeviceRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/DeviceRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ],\n \"servicedPeriod\": {\n \"start\": \"2016-08-10\",\n \"end\": \"2016-08-12\"\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"Prior authorization inquiry details provided\"\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientEvent\",\n \"display\": \"Patient Event\"\n }\n ]\n },\n \"sequence\": 3,\n \"timingPeriod\": {\n \"start\": \"2021-09-01\",\n \"end\": \"2021-09-03\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"admissionDates\",\n \"display\": \"Admission Dates\"\n }\n ]\n },\n \"sequence\": 4,\n \"timingPeriod\": {\n \"start\": \"2021-09-10\",\n \"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingDate\": \"2021-09-13\"\n },\n {\n \"sequence\": 99,\n \"category\": {\n \"coding\": [\n {\n \"system\": \"urn:inferno:pas-codes\",\n \"code\": \"default-profile-testing\",\n \"display\": \"Testing Profile Defaulting\"\n }\n ]\n },\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"Claim/PriorAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": 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},\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": 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\"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ],\n \"servicedPeriod\": {\n \"start\": \"2016-08-10\",\n \"end\": \"2016-08-12\"\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": 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\"end\": \"2021-09-12\"\n }\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"dischargeDates\",\n \"display\": \"Discharge Dates\"\n }\n ]\n },\n \"sequence\": 5,\n \"timingDate\": \"2021-09-13\"\n },\n {\n \"sequence\": 99,\n \"category\": {\n \"coding\": [\n {\n \"system\": \"urn:inferno:pas-codes\",\n \"code\": \"default-profile-testing\",\n \"display\": \"Testing Profile Defaulting\"\n }\n ]\n },\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"Claim/PriorAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"4\",\n \"display\": \"Diagnostic\"\n }\n ]\n }\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"http://unitsofmeasure.org\",\n \"code\": \"1\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"reference\": \"Condition/EncounterDiagnosisExample\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PriorAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PriorAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-jurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-subDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://utilization-management.com/identifiers\",\n \"value\": \"AUTH-PRIOR-0001\"\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2021-01-01\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"code\": \"normal\"\n }\n ]\n },\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"sequence\": 1,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/data-absent-reason\",\n \"code\": \"not-applicable\"\n }\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"1\",\n \"display\": \"Medical Care\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Condition/EncounterDiagnosisExample\",\n \"resource\": {\n \"resourceType\": \"Condition\",\n \"id\": \"EncounterDiagnosisExample\",\n \"clinicalStatus\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-clinical\",\n \"code\": \"active\"\n }\n ]\n },\n \"code\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-category\",\n \"code\": \"problem-list-item\",\n \"display\": \"Problem List Item\"\n }\n ]\n }\n ]\n }\n }\n ]\n }\n]"
65
+ "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"DeviceAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": 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\"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"DeviceRequest/DeviceRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly 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],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1,\n \"unit\": \"visit\"\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": 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{\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\",\n \"display\": \"Explaining Benefits\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-claimaccidenttype\",\n \"code\": \"auto\",\n \"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"Claim/PriorAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMOExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DeviceRequest/DeviceRequestExample\",\n \"resource\": {\n \"resourceType\": \"DeviceRequest\",\n \"id\": \"DeviceRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-devicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"codeCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E1223\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"authoredOn\": \"2005-06-02\",\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"requester\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"reference\": \"Condition/EncounterDiagnosisExample\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PriorAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PriorAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-jurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-subDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://utilization-management.com/identifiers\",\n \"value\": \"AUTH-PRIOR-0001\"\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2021-01-01\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"code\": \"normal\"\n }\n ]\n },\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"sequence\": 1,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/data-absent-reason\",\n \"code\": \"not-applicable\"\n }\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"1\",\n \"display\": \"Medical Care\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Condition/EncounterDiagnosisExample\",\n \"resource\": {\n \"resourceType\": \"Condition\",\n \"id\": \"EncounterDiagnosisExample\",\n \"clinicalStatus\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-clinical\",\n \"code\": \"active\"\n }\n ]\n },\n \"code\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-category\",\n \"code\": \"problem-list-item\",\n \"display\": \"Problem List Item\"\n }\n ]\n }\n ]\n }\n }\n ]\n },\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"ReferralAuthorizationBundleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\",\n \"display\": \"Encounter for Problem\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ],\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter\"\n ],\n \"lastUpdated\": \"2021-09-10T12:00:00Z\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-patientStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1351\",\n \"code\": \"1\",\n \"display\": \"Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n }\n ],\n \"reasonReference\": [\n {\n \"reference\": \"Condition/EncounterDiagnosisExample\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PriorAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PriorAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-jurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-subDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://utilization-management.com/identifiers\",\n \"value\": \"AUTH-PRIOR-0001\"\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2021-01-01\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"code\": \"normal\"\n }\n ]\n },\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"sequence\": 1,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/data-absent-reason\",\n \"code\": \"not-applicable\"\n }\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"1\",\n \"display\": \"Medical Care\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Condition/EncounterDiagnosisExample\",\n \"resource\": {\n \"resourceType\": \"Condition\",\n \"id\": \"EncounterDiagnosisExample\",\n \"clinicalStatus\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-clinical\",\n \"code\": \"active\"\n }\n ]\n },\n \"code\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/condition-category\",\n \"code\": \"problem-list-item\",\n \"display\": \"Problem List Item\"\n }\n ]\n }\n ]\n }\n }\n ]\n }\n]"
66
66
  },
67
67
  {
68
68
  "name": "must_support_pa_inquire_request_payload",
@@ -70,35 +70,35 @@
70
70
  "optional": true,
71
71
  "title": "Additional PAS Inquire Request Payloads",
72
72
  "type": "textarea",
73
- "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"PASBundleInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PASClaimInquiryExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PASClaimInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1136\",\n \"code\": \"07\"\n }\n ]\n }\n },\n {\n \"url\": \"indicator\",\n \"valueBoolean\": true\n },\n {\n \"url\": \"code\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1321\",\n \"code\": \"09\"\n }\n ]\n }\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation\",\n \"extension\": [\n {\n \"url\": \"prognosis\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/923\",\n \"code\": \"1\"\n }\n ]\n }\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-01\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"AUTH-0001\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"ADMIN-REF-0001\"\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"billablePeriod\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": false\n }\n ],\n \"sequence\": 2,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"quantity\": {\n \"value\": 1\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0154\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": false\n }\n ]\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n }\n ],\n \"sequence\": 2,\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"B4185\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"HS\",\n \"display\": \"Health Services Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate\",\n \"valueDate\": \"2022-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/306\",\n \"code\": \"A1\",\n \"display\": \"Certified in total\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"G0155\"\n }\n ]\n }\n }\n ],\n \"sequence\": 3,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"quantity\": {\n \"value\": 1\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": 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\"display\": \"Automobile\"\n }\n ]\n },\n \"locationAddress\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"value\": \"PI-UMOExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": 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JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"value\": \"PI-InsurerExample\",\n \"system\": \"http://davinci-pas.org/fhir/payer-id\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-InsurerExample\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n },\n {\n \"system\": \"https://codesystem.x12.org/005010/1069\",\n \"code\": \"18\",\n \"display\": \"Self\"\n }\n ]\n },\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"EHCPOL\",\n \"display\": \"extended healthcare\"\n }\n ]\n },\n \"period\": {\n \"start\": \"2020-01-01\",\n \"end\": \"2025-12-31\"\n },\n \"class\": [\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"group\",\n \"display\": \"Group\"\n }\n ]\n },\n \"value\": \"GRP-001\",\n \"name\": \"ACME GROUP\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/coverage-class\",\n \"code\": \"plan\",\n \"display\": \"Plan\"\n }\n ]\n },\n \"value\": \"PLAN-001\",\n \"name\": \"PREMIER PLAN\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": 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73
+ "value": "[\n {\n \"resourceType\": \"Bundle\",\n \"id\": \"PASBundleInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/PASClaimInquiryExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"PASClaimInquiryExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers\",\n \"extension\": [\n {\n \"url\": \"applicationSenderCode\",\n \"valueString\": \"SND-0001\"\n },\n {\n \"url\": \"applicationReceiverCode\",\n \"valueString\": \"RCV-0001\"\n },\n {\n \"url\": \"interchangeSenderID\",\n \"valueString\": \"INTER-SND-0001\"\n },\n {\n \"url\": \"interchangeReceiverID\",\n \"valueString\": \"INTER-RCV-0001\"\n }\n ]\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode\",\n \"extension\": [\n {\n \"url\": \"category\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": 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\"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n }\n ]\n }\n]"
74
74
  },
75
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  {
76
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  "name": "claim_update_initial_submit_payload",
77
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  "description": "An example PAS Claim Update $submit request Bundle that Inferno will send to the server under test during the Claim Updates workflow.",
78
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  "title": "PAS $submit Payload: Initial Claim",
79
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  "type": "textarea",
80
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateInitialExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"7893120007\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-Insurer\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\"\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"http://unitsofmeasure.org\",\n \"code\": \"1\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
80
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateInitialExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": 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\"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1,\n \"unit\": \"visit\"\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": 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}\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"7893120007\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"type\": {\n 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\"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": 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\"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"https://codesystem.x12.org/005010/673\",\n \"code\": \"VS\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
81
81
  },
82
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  {
83
83
  "name": "claim_update_add_item_submit_payload",
84
84
  "description": "An example PAS Claim Update $submit request Bundle that Inferno will send to the server under test during the Claim Updates workflow.",
85
85
  "title": "PAS $submit Payload: Update Adding an Item",
86
86
  "type": "textarea",
87
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateAddItemExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate1\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate1\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122335\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"added\"\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationExample\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"7893120007\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-Insurer\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\"\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"http://unitsofmeasure.org\",\n \"code\": \"1\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
87
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateAddItemExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate1\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate1\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": 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\"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n 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\"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"added\"\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n 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\"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": 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\"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": 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}\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 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},\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. 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\"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-Insurer\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\"\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"https://codesystem.x12.org/005010/673\",\n \"code\": \"VS\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
88
88
  },
89
89
  {
90
90
  "name": "claim_update_modify_cancel_submit_payload",
91
91
  "description": "An example PAS Claim Update $submit request Bundle that Inferno will send to the server under test during the Claim Updates workflow.",
92
92
  "title": "PAS $submit Payload: Update Modifying and Canceling Items",
93
93
  "type": "textarea",
94
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateModifyCancelExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate2\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate2\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-09-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122335\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"3\",\n \"display\": \"Cancel\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": true\n }\n ]\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n 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\"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": 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\"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": 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\"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
94
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateModifyCancelExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate2\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate2\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": 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}\n ]\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n },\n 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\"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
95
95
  },
96
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  {
97
97
  "name": "claim_update_cancel_all_submit_payload",
98
98
  "description": "An example PAS Claim Update $submit request Bundle that Inferno will send to the server under test during the Claim Updates workflow.",
99
99
  "title": "PAS $submit Payload: Update Canceling the Entire Request",
100
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  "type": "textarea",
101
- "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateCancelAllExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate3\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate3\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"3\",\n \"display\": \"Cancel\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate2\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-09-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122335\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"3\",\n \"display\": \"Cancel\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": true\n }\n ]\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate2\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate2\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": \"111099\",\n \"assigner\": {\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/USER_ASSIGNED\",\n \"value\": \"9012345678\"\n }\n }\n }\n ],\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\",\n \"code\": \"professional\"\n }\n ]\n },\n \"use\": \"preauthorization\",\n \"patient\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"created\": \"2005-05-02T11:01:00+05:00\",\n \"insurer\": {\n \"reference\": \"Organization/InsurerExample\"\n },\n \"provider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"code\": \"normal\"\n }\n ]\n },\n \"careTeam\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope\",\n \"valueBoolean\": true\n }\n ],\n \"sequence\": 1,\n \"provider\": {\n \"reference\": \"PractitionerRole/ReferralPractitionerRoleExample\"\n },\n \"qualification\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-providerqualification\",\n \"code\": \"604210\"\n }\n ]\n },\n \"role\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"code\": \"primary\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate\",\n \"valueDate\": \"2021-05-10\"\n }\n ],\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"code\": \"G89.4\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"patientreasonforvisit\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"sequence\": 1,\n \"focal\": true,\n \"coverage\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n }\n ],\n \"item\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122334\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"I\",\n \"display\": \"Initial\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 1,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-09-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber\",\n \"valueIdentifier\": {\n \"system\": \"http://davinci-pas.org/ITEM_TRACE_NUMBER\",\n \"value\": \"1122335\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber\",\n \"valueString\": \"1122445\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber\",\n \"valueString\": \"9988311\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1525\",\n \"code\": \"SC\",\n \"display\": \"Specialty Care Review\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"3\",\n \"display\": \"Cancel\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService\",\n \"valueReference\": {\n \"reference\": \"ServiceRequest/ReferralRequestExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator\",\n \"valueBoolean\": false\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1345\",\n \"code\": \"2\",\n \"display\": \"Newly Admitted\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1337\",\n \"code\": \"2\",\n \"display\": \"Intermediate Care Facility (ICF)\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit\",\n \"valueDecimal\": 100\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged\",\n \"valueCode\": \"changed\"\n }\n ],\n \"sequence\": 2,\n \"careTeamSequence\": [\n 1\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"informationSequence\": [\n 1\n ],\n \"revenue\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/revenue-code\",\n \"code\": \"0105\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"system\": \"http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"code\": \"E0110\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2016-08-09\",\n \"unitPrice\": {\n \"value\": 1000,\n \"currency\": \"USD\"\n },\n \"quantity\": {\n \"value\": 1\n },\n \"category\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"productOrService\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set\",\n \"code\": \"11\"\n }\n ]\n },\n \"modifierExtension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled\",\n \"valueBoolean\": true\n }\n ]\n }\n ],\n \"supportingInfo\": [\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"additionalInformation\",\n \"display\": \"Additional Information\"\n }\n ]\n },\n \"sequence\": 1,\n \"valueReference\": {\n \"reference\": \"DocumentReference/episode-summary\"\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation\",\n \"extension\": [\n {\n \"url\": \"reportTypeCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/755\",\n \"code\": \"EB\"\n }\n ]\n }\n }\n ]\n }\n ]\n },\n {\n \"category\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes\",\n \"code\": \"freeFormMessage\",\n \"display\": \"Free Form Message\"\n }\n ]\n },\n \"sequence\": 2,\n \"valueString\": \"1\"\n }\n ],\n \"accident\": {\n \"date\": \"2016-03-09\"\n },\n \"related\": [\n {\n \"claim\": {\n \"reference\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate1\"\n },\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"7893120007\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-Insurer\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\"\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"http://unitsofmeasure.org\",\n \"code\": \"1\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
101
+ "value": "{\n \"resourceType\": \"Bundle\",\n \"id\": \"ClaimUpdateCancelAllExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle\"\n ]\n },\n \"identifier\": {\n \"system\": \"http://davinci-pas.org/SUBMITTER_TRANSACTION_IDENTIFIER\",\n \"value\": \"A12345\"\n },\n \"type\": \"collection\",\n \"timestamp\": \"2005-05-02T11:01:00+05:00\",\n \"entry\": [\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Claim/ReferralAuthorizationUpdate3\",\n \"resource\": {\n \"resourceType\": \"Claim\",\n \"id\": \"ReferralAuthorizationUpdate3\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1338\",\n \"code\": \"U\",\n \"display\": \"Urgent\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter\",\n \"valueReference\": {\n \"reference\": \"Encounter/SurgicalEncounterExample\"\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1322\",\n \"code\": \"3\",\n \"display\": \"Cancel\"\n }\n ]\n }\n }\n ],\n \"identifier\": [\n {\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://www.usps.com/\",\n \"code\": \"MA\"\n }\n ]\n }\n },\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment\",\n \"valueString\": \"223412\"\n }\n ],\n \"system\": \"http://davinci-pas.org/PATIENT_EVENT_TRACE_NUMBER\",\n \"value\": 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\"system\": \"http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship\",\n \"code\": \"prior\"\n }\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/UMOExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"UMOExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"8189991234\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"8189948234\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-UMO\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"X3\"\n }\n ]\n }\n ],\n \"name\": \"DR. JOE SMITH CORPORATION\",\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"contact\": [\n {\n \"telecom\": [\n {\n \"system\": \"other\",\n \"value\": \"http://hl7.org/fhir\"\n }\n ],\n \"name\": {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Organization/InsurerExample\",\n \"resource\": {\n \"resourceType\": \"Organization\",\n \"id\": \"InsurerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"7893120007\"\n },\n {\n \"system\": \"http://terminology.hl7.org/NamingSystem/USEIN\",\n \"value\": \"7239994834\"\n },\n {\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType\",\n \"code\": \"payerid\"\n }\n ]\n },\n \"system\": \"http://davinci-pas.org/fhir/payer-id\",\n \"value\": \"PI-Insurer\"\n }\n ],\n \"active\": true,\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/98\",\n \"code\": \"PR\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"3029993456\"\n }\n ],\n \"name\": \"MARYLAND CAPITAL INSURANCE COMPANY\"\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Coverage/InsuranceExample\",\n \"resource\": {\n \"resourceType\": \"Coverage\",\n \"id\": \"InsuranceExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage\"\n ]\n },\n \"status\": \"active\",\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"1234567cov\"\n },\n {\n \"system\": \"http://davinci-pas.org/MEMBERID\",\n \"value\": \"MEM-1234567\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v2-0203\",\n \"code\": \"MB\",\n \"display\": \"Member Number\"\n }\n ]\n }\n }\n ],\n \"beneficiary\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"payor\": [\n {\n \"reference\": \"Organization/InsurerExample\"\n }\n ],\n \"subscriber\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"subscriberId\": \"12345678901\",\n \"relationship\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/subscriber-relationship\",\n \"code\": \"self\"\n }\n ]\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Patient/SubscriberExample\",\n \"resource\": {\n \"resourceType\": \"Patient\",\n \"id\": \"SubscriberExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber\"\n ]\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus\",\n \"valueCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/584\",\n \"code\": \"RU\"\n }\n ]\n }\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2106-3\",\n \"display\": \"White\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Caucasian\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-race\"\n },\n {\n \"extension\": [\n {\n \"url\": \"ombCategory\",\n \"valueCoding\": {\n \"system\": \"urn:oid:2.16.840.1.113883.6.238\",\n \"code\": \"2135-2\",\n \"display\": \"Hispanic or Latino\"\n }\n },\n {\n \"url\": \"text\",\n \"valueString\": \"Filipino\"\n }\n ],\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity\"\n },\n {\n \"url\": \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex\",\n \"valueCode\": \"M\"\n }\n ],\n \"identifier\": [\n {\n \"system\": \"http://davinci-pas.org/MIN\",\n \"value\": \"12345678901\"\n }\n ],\n \"name\": [\n {\n \"family\": \"SMITH\",\n \"given\": [\n \"JOE\"\n ],\n \"prefix\": [\n \"Mr\"\n ],\n \"suffix\": [\n \"PharmD\"\n ]\n }\n ],\n \"gender\": \"male\",\n \"birthDate\": \"1987-02-20\",\n \"multipleBirthInteger\": 1,\n \"communication\": [\n {\n \"language\": {\n \"coding\": [\n {\n \"system\": \"urn:ietf:bcp:47\",\n \"code\": \"nl-NL\",\n \"display\": \"Dutch (Netherlands)\"\n }\n ]\n },\n \"preferred\": true\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"555-555-5555\",\n \"use\": \"home\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"49 Meadow St\"\n ],\n \"city\": \"Mounds\",\n \"state\": \"OK\",\n \"district\": \"Meadow\",\n \"postalCode\": \"74047\",\n \"country\": \"US\",\n \"period\": {\n \"start\": \"2016-12-06\",\n \"end\": \"2020-07-22\"\n }\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/ServiceRequest/ReferralRequestExample\",\n \"resource\": {\n \"resourceType\": \"ServiceRequest\",\n \"id\": \"ReferralRequestExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-servicerequest\"\n ]\n },\n \"status\": \"active\",\n \"intent\": \"order\",\n \"code\": {\n \"coding\": [\n {\n \"system\": \"https://codesystem.x12.org/005010/1365\",\n \"code\": \"3\",\n \"display\": \"Consultation\"\n }\n ]\n },\n \"occurrenceTiming\": {\n \"repeat\": {\n \"duration\": 15,\n \"durationMax\": 25,\n \"durationUnit\": \"min\",\n \"frequency\": 1,\n \"frequencyMax\": 4,\n \"period\": 1,\n \"periodUnit\": \"d\"\n }\n },\n \"extension\": [\n {\n \"url\": \"http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information\",\n \"extension\": [\n {\n \"url\": \"coverage\",\n \"valueReference\": {\n \"reference\": \"Coverage/InsuranceExample\"\n }\n },\n {\n \"url\": \"covered\",\n \"valueCode\": \"covered\"\n },\n {\n \"url\": \"pa-needed\",\n \"valueCode\": \"auth-needed\"\n },\n {\n \"url\": \"date\",\n \"valueDate\": \"2021-09-10\"\n },\n {\n \"url\": \"coverage-assertion-id\",\n \"valueString\": \"1122445\"\n }\n ]\n }\n ],\n \"quantityQuantity\": {\n \"value\": 1,\n \"unit\": \"visit\",\n \"system\": \"https://codesystem.x12.org/005010/673\",\n \"code\": \"VS\"\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/PractitionerRole/ReferralPractitionerRoleExample\",\n \"resource\": {\n \"resourceType\": \"PractitionerRole\",\n \"id\": \"ReferralPractitionerRoleExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole\"\n ]\n },\n \"practitioner\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"organization\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"location\": [\n {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n ],\n \"code\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/practitioner-role\",\n \"code\": \"doctor\",\n \"display\": \"Doctor\"\n }\n ]\n }\n ],\n \"specialty\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"408443003\",\n \"display\": \"General medical practice\"\n }\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"endpoint\": [\n {\n \"display\": \"Mock Endpoint\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Practitioner/ReferralPractitionerExample\",\n \"resource\": {\n \"resourceType\": \"Practitioner\",\n \"id\": \"ReferralPractitionerExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"http://hl7.org/fhir/sid/us-npi\",\n \"value\": \"1234567893\"\n }\n ],\n \"name\": [\n {\n \"family\": \"WATSON\",\n \"given\": [\n \"SUSAN\"\n ]\n }\n ],\n \"telecom\": [\n {\n \"system\": \"phone\",\n \"value\": \"4029993456\"\n }\n ],\n \"address\": [\n {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n ]\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Location/ReferralLocationExample\",\n \"resource\": {\n \"resourceType\": \"Location\",\n \"id\": \"ReferralLocationExample\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-location\"\n ]\n },\n \"name\": \"REFERRAL CLINIC\",\n \"address\": {\n \"line\": [\n \"111 1ST STREET\"\n ],\n \"city\": \"SAN DIEGO\",\n \"state\": \"CA\",\n \"postalCode\": \"92101\",\n \"country\": \"US\"\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/DocumentReference/episode-summary\",\n \"resource\": {\n \"resourceType\": \"DocumentReference\",\n \"id\": \"episode-summary\",\n \"meta\": {\n \"profile\": [\n \"http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference\"\n ]\n },\n \"identifier\": [\n {\n \"system\": \"urn:ietf:rfc:3986\",\n \"value\": \"urn:oid:2.16.840.1.113883.19.5.99999.1\"\n }\n ],\n \"status\": \"current\",\n \"type\": {\n \"coding\": [\n {\n \"system\": \"http://loinc.org\",\n \"code\": \"34133-9\",\n \"display\": \"Summary of episode note\"\n }\n ],\n \"text\": \"CCD Document\"\n },\n \"category\": [\n {\n \"coding\": [\n {\n \"system\": \"http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category\",\n \"code\": \"clinical-note\",\n \"display\": \"Clinical Note\"\n }\n ],\n \"text\": \"Clinical Note\"\n }\n ],\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"date\": \"2016-03-09T15:29:46Z\",\n \"author\": [\n {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n }\n ],\n \"description\": \"Pulmonology clinic acute visit\",\n \"content\": [\n {\n \"attachment\": {\n \"contentType\": \"text/plain\",\n \"url\": \"/Binary/1-note\",\n \"title\": \"Uri where the data can be found: [base]/Binary/1-note\"\n },\n \"format\": {\n \"system\": \"urn:oid:1.3.6.1.4.1.19376.1.2.3\",\n \"code\": \"urn:hl7-org:sdwg:ccda-structuredBody:2.1\",\n \"display\": \"Documents following C-CDA constraints using a structured body\"\n }\n }\n ],\n \"context\": {\n \"period\": {\n \"start\": \"2004-12-23T08:00:00+11:00\",\n \"end\": \"2004-12-23T08:01:00+11:00\"\n }\n }\n }\n },\n {\n \"fullUrl\": \"http://davinci-pas.org/fhir/Encounter/SurgicalEncounterExample\",\n \"resource\": {\n \"resourceType\": \"Encounter\",\n \"id\": \"SurgicalEncounterExample\",\n \"identifier\": [\n {\n \"use\": \"temp\",\n \"system\": \"http://www.temp.com\",\n \"value\": \"Encounter_SubscriberExample_20130404\"\n }\n ],\n \"status\": \"planned\",\n \"class\": {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ActCode\",\n \"code\": \"AMB\",\n \"display\": \"ambulatory\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"11429006\",\n \"display\": \"Consultation\"\n }\n ]\n }\n ],\n \"priority\": {\n \"coding\": [\n {\n \"system\": \"http://snomed.info/sct\",\n \"code\": \"17621005\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"subject\": {\n \"reference\": \"Patient/SubscriberExample\"\n },\n \"participant\": [\n {\n \"individual\": {\n \"reference\": \"Practitioner/ReferralPractitionerExample\"\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/v3-ParticipationType\",\n \"code\": \"REF\"\n }\n ]\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n }\n }\n ],\n \"reasonCode\": [\n {\n \"text\": \"The patient had fever peaks over the last couple of days. He is worried about these peaks.\"\n }\n ],\n \"period\": {\n \"start\": \"2020-07-02\",\n \"end\": \"2020-07-09\"\n },\n \"serviceProvider\": {\n \"reference\": \"Organization/UMOExample\"\n },\n \"hospitalization\": {\n \"admitSource\": {\n \"coding\": [\n {\n \"system\": \"https://www.nubc.org/CodeSystem/PointOfOrigin\",\n \"code\": \"5\"\n }\n ]\n },\n \"dischargeDisposition\": {\n \"coding\": [\n {\n \"system\": \"http://terminology.hl7.org/CodeSystem/discharge-disposition\",\n \"code\": \"oth\"\n }\n ]\n }\n },\n \"location\": [\n {\n \"location\": {\n \"reference\": \"Location/ReferralLocationExample\"\n }\n }\n ]\n }\n }\n ]\n}"
102
102
  }
103
103
  ]
104
104
  }