Da Vinci Payer Data Exchange
2.1.0 - STU2 United States of America flag

Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

Example ExplanationOfBenefit: PdexPriorAuth

Page standards status: Informative

Generated Narrative: ExplanationOfBenefit

ResourceExplanationOfBenefit "PDexPriorAuth1" Updated "2024-02-06 09:14:11+0000" (Language "en-US")

Profile: PDex Prior Authorization

LevelOfServiceCode: Urgent (1338#U)

identifier: https://www.exampleplan.com/fhir/EOBIdentifier/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)

Relateds

-RelationshipReference
*Associated Claim (Example Related Claim Relationship Codes#associated)XCLM1001

outcome: queued

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

CareTeams

-SequenceProviderResponsible
*1Organization/Payer1 "Payer 1"true

Diagnoses

-SequenceDiagnosis[x]Type
*1Chronic pain syndrome (International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)#G89.4)Principal Diagnosis (Example Diagnosis Type Codes#principal)

Insurances

-FocalCoverage
*trueCoverage/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

1

ReviewAction

url

number

value: AUTH0001

url

ReviewActionCode

value: Certified in total (306#A1)

category: Submitted Amount (Adjudication Value Codes#submitted)

Amounts

-ValueCurrency
*300.99USD

total

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

category: Eligible (Prior Authorization Values#eligible)

Amounts

-ValueCurrency
*100USD