Da Vinci Payer Data Exchange
2.0.0 - STU2
Da Vinci Payer Data Exchange
2.0.0 - STU2
This page is part of the Da Vinci Payer Data Exchange (v2.0.0: STU2) 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
Generated Narrative: ExplanationOfBenefit
Resource ExplanationOfBenefit "PDexPriorAuth1" Updated "2021-10-12 09:14:11+0000" (Language "en-US")
LevelOfServiceCode: Urgent (1338#U)
identifier: id: PA123412341234123412341234
status: active
type: Institutional (Claim Type Codes#institutional)
use: preauthorization
patient: Patient/1 " APPLESEED"
billablePeriod: 2021-10-01 --> 2021-10-31
created: 2021-09-20 00:00:00+0000
insurer: Organization/Payer1: Example Health Plan "Payer 1"
provider: Organization/Payer2: Another Example Health Plan "Payer 2"
priority: Normal (Process Priority Codes#normal)
fundsReserveRequested: Provider (Funds Reservation Codes#provider)
fundsReserve: None (Funds Reservation Codes#none)
| Relationship | Reference |
| Associated Claim (Example Related Claim Relationship Codes#associated) | id: XCLM1001 |
outcome: queued
preAuthRefPeriod: 2021-10-01 --> 2021-10-31
| Sequence | Provider | Responsible |
| 1 | Organization/Payer1 "Payer 1" | true |
| Sequence | Diagnosis[x] | Type |
| 1 | Chronic pain syndrome (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G89.4) | Principal Diagnosis (Example Diagnosis Type Codes#principal) |
| Focal | Coverage |
| true | Coverage/Coverage1 |
item
sequence: 1
category: Consultation (X12 Service Type Codes#3)
productOrService: Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full) (Health Insurance Prospective Payment System (HIPPS)#BB201)
adjudication
id
1ReviewAction
url
numbervalue: AUTH0001
url
ReviewActionCodevalue: Certified in total (306#A1)
category: Submitted Amount (Adjudication Value Codes#submitted)
Amounts
Value Currency 300.99 USD
total
An attribute to express the amount of a service or item that has been utilized: 1
category: Eligible (Prior Authorization Values#eligible)
Amounts
Value Currency 100 USD
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pdex#2.0.0 based on FHIR 4.0.1. Generated 2024-01-06
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