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
@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 "2021-10-12T09:14:11+00:00"^^xsd:dateTime ] ;
( fhir:profile [
fhir:v "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0> ] )
] ; #
fhir:language [ fhir:v "en-US"] ; #
fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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 "PDexPriorAuth1" Updated "2021-10-12 09:14:11+0000" (Language "en-US") </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: PA123412341234123412341234</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> " APPLESEED"</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\">Organization/Payer1: Example Health Plan</a> "Payer 1"</p><p><b>provider</b>: <a href=\"Organization-Payer2.html\">Organization/Payer2: Another Example Health Plan</a> "Payer 2"</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: 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/Payer1</a> "Payer 1"</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>"
] ; #
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:category [
( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/adjudication"^^xsd:anyURI ] ;
fhir:code [ fhir:v "submitted" ] ] ) ] ;
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 © 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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