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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

: PdexPriorAuth - JSON Representation

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "PDexPriorAuth1",
  "meta" : {
    "lastUpdated" : "2021-10-12T09:14:11+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0"
    ]
  },
  "language" : "en-US",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p><b>Generated Narrative: ExplanationOfBenefit</b><a name=\"PDexPriorAuth1\"> </a></p><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\">Resource ExplanationOfBenefit &quot;PDexPriorAuth1&quot; Updated &quot;2021-10-12 09:14:11+0000&quot;  (Language &quot;en-US&quot;) </p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-pdex-priorauthorization.html\">PDex Prior Authorization (version 2.0.0)</a></p></div><p><b>LevelOfServiceCode</b>: Urgent <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1338#U)</span></p><p><b>identifier</b>: id:\u00a0PA123412341234123412341234</p><p><b>status</b>: active</p><p><b>type</b>: Institutional <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-claim-type.html\">Claim Type Codes</a>#institutional)</span></p><p><b>use</b>: preauthorization</p><p><b>patient</b>: <a href=\"Patient-1.html\">Patient/1</a> &quot; APPLESEED&quot;</p><p><b>billablePeriod</b>: 2021-10-01 --&gt; 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\">Organization/Payer1: Example Health Plan</a> &quot;Payer 1&quot;</p><p><b>provider</b>: <a href=\"Organization-Payer2.html\">Organization/Payer2: Another Example Health Plan</a> &quot;Payer 2&quot;</p><p><b>priority</b>: Normal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-processpriority.html\">Process Priority Codes</a>#normal)</span></p><p><b>fundsReserveRequested</b>: Provider <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-fundsreserve.html\">Funds Reservation Codes</a>#provider)</span></p><p><b>fundsReserve</b>: None <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-fundsreserve.html\">Funds Reservation Codes</a>#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>Associated Claim <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-ex-relatedclaimrelationship.html\">Example Related Claim Relationship Codes</a>#associated)</span></td><td>id:\u00a0XCLM1001</td></tr></table><p><b>outcome</b>: queued</p><p><b>preAuthRefPeriod</b>: 2021-10-01 --&gt; 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/Payer1</a> &quot;Payer 1&quot;</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>Chronic pain syndrome <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-icd10CM.html\">International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)</a>#G89.4)</span></td><td>Principal Diagnosis <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-ex-diagnosistype.html\">Example Diagnosis Type Codes</a>#principal)</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/Coverage1</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: Consultation <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.3.0/CodeSystem-X12ServiceTypeCodes.html\">X12 Service Type Codes</a>#3)</span></p><p><b>productOrService</b>: Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-HIPPS.html\">Health Insurance Prospective Payment System (HIPPS)</a>#BB201)</span></p><blockquote><p><b>adjudication</b></p><blockquote><p><b>id</b></p>1</blockquote><blockquote><p><b>ReviewAction</b></p><blockquote><p><b>url</b></p><code>number</code></blockquote><p><b>value</b>: AUTH0001</p><blockquote><p><b>url</b></p><a href=\"StructureDefinition-extension-reviewActionCode.html\">ReviewActionCode</a></blockquote><p><b>value</b>: Certified in total <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (306#A1)</span></p></blockquote><p><b>category</b>: Submitted Amount <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.0.0/CodeSystem-adjudication.html\">Adjudication Value Codes</a>#submitted)</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>USD</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>An attribute to express the amount of a service or item that has been utilized</b>: 1</p><p><b>category</b>: Eligible <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"CodeSystem-PriorAuthorizationValueCodes.html\">Prior Authorization Values</a>#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>USD</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"
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }
            ]
          },
          "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"
      }
    }
  ]
}