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| Page standards status: Informative |
Resource Claim "SurgicalAuthorizationRequestExample"
Profile: PAS Claim
LevelOfServiceCode: Elective (1338#E)
Extension Definition for Claim.encounter for Version 5.0: Encounter/SurgicalEncounterExample
ConditionCode
url
categoryvalue: 07 (1136#07)
url
indicatorvalue: true
url
codevalue: 09 (1321#09)
identifier: id: 16139462398
status: active
type: Institutional (Claim Type Codes#institutional)
use: preauthorization
patient: Patient/SubscriberExample " SMITH"
created: 2020-06-24 07:34:00+0500
insurer: Organization/InsurerExample "MARYLAND CAPITAL INSURANCE COMPANY"
provider: Organization/UMOExample "DR. JOE SMITH CORPORATION"
priority: Normal (Process Priority Codes#normal)
| Extension | Sequence | Provider |
| 1 | PractitionerRole/SurgicalPractitionerRoleExample |
| Sequence | Category | Timing[x] |
| 1 | Admission Dates (PAS Temporary Codes#admissionDates) | 2020-07-02 --> 2020-07-09 |
| Extension | Sequence | Diagnosis[x] |
| 1 | C18.9 (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#C18.9) |
| Sequence | Focal | Coverage |
| 1 | true | Coverage/InsuranceExample |
| Extension | Sequence | CareTeamSequence | DiagnosisSequence | Category | ProductOrService | Location[x] |
| , , , , | 1 | 1 | 1 | Surgical (1365#2) | Under Venous Grafting Only for Coronary Artery Bypass (HCPCSReleaseCodeSets#33510) | 21 (CMS Place of Service Codes (POS)#21) |