Da Vinci Payer Data Exchange
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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-ballot 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

: PdexPriorAuth - JSON Representation

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{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "PDexPriorAuth1",
  "meta" : {
    "lastUpdated" : "2024-02-06T09:14:11+00:00",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization"
    ]
  },
  "language" : "en-US",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en-US\" lang=\"en-US\"><p class=\"res-header-id\"><b>Generated Narrative: ExplanationOfBenefit PDexPriorAuth1</b></p><a name=\"PDexPriorAuth1\"> </a><a name=\"hcPDexPriorAuth1\"> </a><a name=\"PDexPriorAuth1-en-US\"> </a><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\">Last updated: 2024-02-06 09:14:11+0000; Language: en-US</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-pdex-priorauthorization.html\">PDex Prior Authorization</a></p></div><p><b>identifier</b>: <code>https://www.exampleplan.com/fhir/EOBIdentifier</code>/PA123412341234123412341234</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Preauthorization</p><p><b>patient</b>: <a href=\"Patient-1.html\">Johnny Appleseed  Male, DoB: 1986-01-01 ( Member Number)</a></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\">Example Health Plan</a></p><p><b>provider</b>: <a href=\"Organization-Payer2.html\">Another Example Health Plan</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>fundsReserveRequested</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/fundsreserve provider}\">Provider</span></p><p><b>fundsReserve</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/fundsreserve none}\">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><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship associated}\">Associated Claim</span></td><td>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 Payer 1</a></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><span title=\"Codes:{http://hl7.org/fhir/sid/icd-10-cm G89.4}\">Chronic pain syndrome</span></td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/ex-diagnosistype principal}\">Principal Diagnosis</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: identifier = Member Number; status = active; subscriberId = 93542106; relationship = Self</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:{https://x12.org/codes/service-type-codes 3}\">Consultation</span></p><p><b>productOrService</b>: <span title=\"Codes:{https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes BB201}\">Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)</span></p><blockquote><p><b>adjudication</b></p><blockquote><p><b>id</b></p>1</blockquote><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/adjudication submitted}\">Submitted Amount</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>United States dollar</td></tr></table></blockquote></blockquote><blockquote><p><b>total</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes eligible}\">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>United States dollar</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"
            },
            {
              "url" : "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated",
              "valueDateTime" : "2024-07-23T17:26:23.217+00:00"
            }
          ],
          "category" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted",
                "display" : "Submitted Amount"
              }
            ]
          },
          "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"
      }
    }
  ]
}