Da Vinci Payer Data Exchange
2.1.0 - STU 2.1 United States of America flag

This page is part of the Da Vinci Payer Data Exchange (v2.1.0: STU2.1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example ExplanationOfBenefit: PdexPriorAuth

Page standards status: Informative

Last updated: 2024-02-06 09:14:11+0000; Language: en-US

Profile: PDex Prior Authorization

LevelOfServiceCode: Urgent

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

Relateds

-RelationshipReference
*Associated ClaimXCLM1001

outcome: Queued

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

CareTeams

-SequenceProviderResponsible
*1Organization Payer 1true

Diagnoses

-SequenceDiagnosis[x]Type
*1Chronic pain syndromePrincipal Diagnosis

Insurances

-FocalCoverage
*trueCoverage: 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

1

ReviewAction

  • number: AUTH0001
  • http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode: Certified in total

When Adjudicated: 2024-07-23 17:26:23+0000

category: Submitted Amount

Amounts

-ValueCurrency
*300.99United States dollar

total

An attribute to express the amount of a service or item that has been utilized: 1

category: Eligible

Amounts

-ValueCurrency
*100United States dollar