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 |
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:ExplanationOfBenefit ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "PDexPriorAuth1"] ; #
fhir:meta [
fhir:lastUpdated [ fhir:v "2024-02-06T09:14:11+00:00"^^xsd:dateTime ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"
] ; #
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/1338"^^xsd:anyURI ] ;
fhir:code [ fhir:v "U" ] ;
fhir:display [ fhir:v "Urgent" ] ] ) ]
] ) ; #
fhir:identifier ( [
fhir:system [ fhir:v "https://www.exampleplan.com/fhir/EOBIdentifier"^^xsd:anyURI ] ;
fhir:value [ fhir:v "PA123412341234123412341234" ]
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/claim-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "institutional" ] ] ) ;
fhir:text [ fhir:v "Institutional" ]
] ; #
fhir:use [ fhir:v "preauthorization"] ; #
fhir:patient [
fhir:reference [ fhir:v "Patient/1" ]
] ; #
fhir:billablePeriod [
fhir:start [ fhir:v "2021-10-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-10-31"^^xsd:date ]
] ; #
fhir:created [ fhir:v "2021-09-20T00:00:00+00:00"^^xsd:dateTime] ; #
fhir:insurer [
fhir:reference [ fhir:v "Organization/Payer1" ] ;
fhir:display [ fhir:v "Example Health Plan" ]
] ; #
fhir:provider [
fhir:reference [ fhir:v "Organization/Payer2" ] ;
fhir:display [ fhir:v "Another Example Health Plan" ]
] ; #
fhir:priority [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/processpriority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "normal" ] ;
fhir:display [ fhir:v "Normal" ] ] )
] ; #
fhir:fundsReserveRequested [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/fundsreserve"^^xsd:anyURI ] ;
fhir:code [ fhir:v "provider" ] ;
fhir:display [ fhir:v "Provider" ] ] )
] ; #
fhir:fundsReserve [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/fundsreserve"^^xsd:anyURI ] ;
fhir:code [ fhir:v "none" ] ;
fhir:display [ fhir:v "None" ] ] )
] ; #
fhir:related ( [
fhir:relationship [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"^^xsd:anyURI ] ;
fhir:code [ fhir:v "associated" ] ;
fhir:display [ fhir:v "Associated Claim" ] ] ) ] ;
fhir:reference [
fhir:value [ fhir:v "XCLM1001" ] ]
] ) ; #
fhir:outcome [ fhir:v "queued"] ; #
fhir:preAuthRefPeriod ( [
fhir:start [ fhir:v "2021-10-01"^^xsd:date ] ;
fhir:end [ fhir:v "2021-10-31"^^xsd:date ]
] ) ; #
fhir:careTeam ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:provider [
fhir:reference [ fhir:v "Organization/Payer1" ] ] ;
fhir:responsible [ fhir:v "true"^^xsd:boolean ]
] ) ; #
fhir:diagnosis ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:diagnosis [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-10-cm"^^xsd:anyURI ] ;
fhir:code [ fhir:v "G89.4" ] ] ) ] ;
( fhir:type [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/ex-diagnosistype"^^xsd:anyURI ] ;
fhir:code [ fhir:v "principal" ] ] ) ] )
] ) ; #
fhir:insurance ( [
fhir:focal [ fhir:v "true"^^xsd:boolean ] ;
fhir:coverage [
fhir:reference [ fhir:v "Coverage/Coverage1" ] ]
] ) ; #
fhir:item ( [
fhir:sequence [ fhir:v "1"^^xsd:positiveInteger ] ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "https://x12.org/codes/service-type-codes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "3" ] ;
fhir:display [ fhir:v "Consultation" ] ] ) ] ;
fhir:productOrService [
( fhir:coding [
fhir:system [ fhir:v "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "BB201" ] ;
fhir:display [ fhir:v "Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)" ] ] ) ] ;
( fhir:adjudication [
fhir:id [ fhir:v "1" ] ;
( fhir:extension [
( fhir:extension [
fhir:url [ fhir:v "number"^^xsd:anyURI ] ;
fhir:value [ fhir:v "AUTH0001" ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
( fhir:coding [
fhir:system [ fhir:v "https://codesystem.x12.org/005010/306"^^xsd:anyURI ] ;
fhir:code [ fhir:v "A1" ] ;
fhir:display [ fhir:v "Certified in total" ] ] ) ] ] ) ;
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction"^^xsd:anyURI ] ] [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2024-07-23T17:26:23.217+00:00"^^xsd:dateTime ] ] ) ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ;
fhir:display [ fhir:v "Submitted Amount" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "300.99"^^xsd:decimal ] ;
fhir:currency [ fhir:v "USD" ] ] ] )
] ) ; #
fhir:total ( [
( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization"^^xsd:anyURI ] ;
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "1"^^xsd:decimal ] ] ] ) ;
fhir:category [
( fhir:coding [
fhir:system [ fhir:v "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "eligible" ] ;
fhir:display [ fhir:v "Eligible" ] ] ) ] ;
fhir:amount [
fhir:value [ fhir:v "100"^^xsd:decimal ] ;
fhir:currency [ fhir:v "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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