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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 - XML Representation

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<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="PDexPriorAuth1"/>
  <meta>
    <lastUpdated value="2021-10-12T09:14:11+00:00"/>
    <profile
             value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="extensions"/>
    <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: 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> &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: XCLM1001</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>
  </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>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>
          <code value="submitted"/>
        </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>