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