Da Vinci Payer Data Exchange
2.1.0-ballot - STU2 Ballot
Da Vinci Payer Data Exchange
2.1.0-ballot - STU2 Ballot
This page is part of the Da Vinci Payer Data Exchange (v2.1.0-ballot: STU2.1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
Generated Narrative: ExplanationOfBenefit PDexPriorAuth1
Last updated: 2024-02-06 09:14:11+0000; Language: en-US
Profile: PDex Prior Authorization
identifier: https://www.exampleplan.com/fhir/EOBIdentifier/PA123412341234123412341234
status: Active
type: Institutional
use: Preauthorization
patient: Johnny Appleseed Male, DoB: 1986-01-01 ( Member Number)
billablePeriod: 2021-10-01 --> 2021-10-31
created: 2021-09-20 00:00:00+0000
insurer: Example Health Plan
provider: Another Example Health Plan
priority: Normal
fundsReserveRequested: Provider
fundsReserve: None
| Relationship | Reference |
| Associated Claim | XCLM1001 |
outcome: Queued
preAuthRefPeriod: 2021-10-01 --> 2021-10-31
| Sequence | Provider | Responsible |
| 1 | Organization Payer 1 | true |
| Sequence | Diagnosis[x] | Type |
| 1 | Chronic pain syndrome | Principal Diagnosis |
| Focal | Coverage |
| true | Coverage: identifier = Member Number; status = active; subscriberId = 93542106; relationship = Self |
item
sequence: 1
category: Consultation
productOrService: Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)
adjudication
id
1category: Submitted Amount
Amounts
Value Currency 300.99 United States dollar
total
category: Eligible
Amounts
Value Currency 100 United States dollar
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pdex#2.1.0-ballot based on FHIR 4.0.1. Generated 2024-08-14
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