Da Vinci Payer Data Exchange
2.0.0-ballot - ballot US

This page is part of the Da Vinci Payer Data Exchange (v2.0.0-ballot: STU2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: PdexPriorAuth

Generated Narrative

Resource "PDexPriorAuth1" Updated "2021-10-12 09:14:11+0000" (Language "en-US")

Profile: PDex Prior Authorization (version 2.0.0-ballot)

identifier: id: PA123412341234123412341234

status: active

type: Institutional (Claim Type Codes#institutional)

use: preauthorization

patient: Patient/1 " APPLESEED"

billablePeriod: 2021-10-01 --> 2021-10-31

created: 2021-09-20 12:00:00+0000

insurer: Organization/Payer1: Example Health Plan "Payer 1"

provider: Organization/Payer2: Another Example Health Plan "Payer 2"

priority: Normal (Process Priority Codes#normal)

fundsReserveRequested: Provider (Funds Reservation Codes#provider)

fundsReserve: None (Funds Reservation Codes#none)

Relateds

-RelationshipReference
*Associated Claim (Example Related Claim Relationship Codes#associated)id: XCLM1001

outcome: queued

preAuthRefPeriod: 2021-10-01 --> 2021-10-31

CareTeams

-SequenceProviderResponsible
*1Organization/Payer1 "Payer 1"true

Diagnoses

-SequenceDiagnosis[x]Type
*1Chronic pain syndrome (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G89.4)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-FocalCoverage
*trueCoverage/Coverage1

item

sequence: 1

category: Consultation (service-type-codes#3)

productOrService: 99202 (Current Procedural Terminology (CPT®)#99202)

adjudication

category: Submitted Amount (Adjudication Value Codes#submitted)