Da Vinci Payer Data Exchange
2.1.0 - STU2
Da Vinci Payer Data Exchange
2.1.0 - STU2
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
{
"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" : "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><a name=\"hcPDexPriorAuth1\"> </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 "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>LevelOfServiceCode</b>: Urgent <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (1338#U)</span></p><p><b>identifier</b>: <code>https://www.exampleplan.com/fhir/EOBIdentifier</code>/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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/CodeSystem-ex-relatedclaimrelationship.html\">Example Related Claim Relationship Codes</a>#associated)</span></td><td>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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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/5.5.0/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",
"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"
}
}
]
}
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pdex#2.1.0 based on FHIR 4.0.1. Generated 2024-04-29
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change