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 |
{
"resourceType" : "ExplanationOfBenefit",
"id" : "PDexPriorAuth1",
"meta" : {
"lastUpdated" : "2024-02-06T09:14:11+00:00",
"profile" : [
🔗 "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PDexPriorAuth1</b></p><a name=\"PDexPriorAuth1\"> </a><a name=\"hcPDexPriorAuth1\"> </a><a name=\"PDexPriorAuth1-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2024-02-06 09:14:11+0000; Language: en-US</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-pdex-priorauthorization.html\">PDex Prior Authorization</a></p></div><p><b>identifier</b>: <code>https://www.exampleplan.com/fhir/EOBIdentifier</code>/PA123412341234123412341234</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-1.html\">Johnny Appleseed Male, DoB: 1986-01-01 ( Member Number)</a></p><p><b>billablePeriod</b>: 2021-10-01 --> 2021-10-31</p><p><b>created</b>: 2021-09-20 00:00:00+0000</p><p><b>insurer</b>: <a href=\"Organization-Payer1.html\">Example Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-Payer2.html\">Another Example Health Plan</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>fundsReserveRequested</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/fundsreserve provider}\">Provider</span></p><p><b>fundsReserve</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/fundsreserve none}\">None</span></p><h3>Relateds</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Relationship</b></td><td><b>Reference</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship associated}\">Associated Claim</span></td><td>XCLM1001</td></tr></table><p><b>outcome</b>: Queued</p><p><b>preAuthRefPeriod</b>: 2021-10-01 --> 2021-10-31</p><h3>CareTeams</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Provider</b></td><td><b>Responsible</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><a href=\"Organization-Payer1.html\">Organization Payer 1</a></td><td>true</td></tr></table><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm G89.4}\">Chronic pain syndrome</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</span></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>true</td><td><a href=\"Coverage-Coverage1.html\">Coverage: identifier = Member Number; status = active; subscriberId = 93542106; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://x12.org/codes/service-type-codes 3}\">Consultation</span></p><p><b>productOrService</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes BB201}\">Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)</span></p><blockquote><p><b>adjudication</b></p><blockquote><p><b>id</b></p>1</blockquote><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>300.99</td><td>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes eligible}\">Eligible</span></p><h3>Amounts</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>100</td><td>United States dollar</td></tr></table></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/1338",
"code" : "U",
"display" : "Urgent"
}
]
}
}
],
"identifier" : [
{
"system" : "https://www.exampleplan.com/fhir/EOBIdentifier",
"value" : "PA123412341234123412341234"
}
],
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/claim-type",
"code" : "institutional"
}
],
"text" : "Institutional"
},
"use" : "preauthorization",
"patient" : {
🔗 "reference" : "Patient/1"
},
"billablePeriod" : {
"start" : "2021-10-01",
"end" : "2021-10-31"
},
"created" : "2021-09-20T00:00:00+00:00",
"insurer" : {
🔗 "reference" : "Organization/Payer1",
"display" : "Example Health Plan"
},
"provider" : {
🔗 "reference" : "Organization/Payer2",
"display" : "Another Example Health Plan"
},
"priority" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/processpriority",
"code" : "normal",
"display" : "Normal"
}
]
},
"fundsReserveRequested" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/fundsreserve",
"code" : "provider",
"display" : "Provider"
}
]
},
"fundsReserve" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/fundsreserve",
"code" : "none",
"display" : "None"
}
]
},
"related" : [
{
"relationship" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
"code" : "associated",
"display" : "Associated Claim"
}
]
},
"reference" : {
"value" : "XCLM1001"
}
}
],
"outcome" : "queued",
"preAuthRefPeriod" : [
{
"start" : "2021-10-01",
"end" : "2021-10-31"
}
],
"careTeam" : [
{
"sequence" : 1,
"provider" : {
🔗 "reference" : "Organization/Payer1"
},
"responsible" : true
}
],
"diagnosis" : [
{
"sequence" : 1,
"diagnosisCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/sid/icd-10-cm",
"code" : "G89.4"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/ex-diagnosistype",
"code" : "principal"
}
]
}
]
}
],
"insurance" : [
{
"focal" : true,
"coverage" : {
🔗 "reference" : "Coverage/Coverage1"
}
}
],
"item" : [
{
"sequence" : 1,
"category" : {
"coding" : [
{
"system" : "https://x12.org/codes/service-type-codes",
"code" : "3",
"display" : "Consultation"
}
]
},
"productOrService" : {
"coding" : [
{
"system" : "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes",
"code" : "BB201",
"display" : "Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)"
}
]
},
"adjudication" : [
{
"id" : "1",
"extension" : [
{
"extension" : [
{
"url" : "number",
"valueString" : "AUTH0001"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://codesystem.x12.org/005010/306",
"code" : "A1",
"display" : "Certified in total"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction"
},
{
"url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated",
"valueDateTime" : "2024-07-23T17:26:23.217+00:00"
}
],
"category" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/adjudication",
"code" : "submitted",
"display" : "Submitted Amount"
}
]
},
"amount" : {
"value" : 300.99,
"currency" : "USD"
}
}
]
}
],
"total" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization",
"valueQuantity" : {
"value" : 1
}
}
],
"category" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes",
"code" : "eligible",
"display" : "Eligible"
}
]
},
"amount" : {
"value" : 100,
"currency" : "USD"
}
}
]
}
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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