Da Vinci Payer Data Exchange
2.2.0 - STU 2.2 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 2.2.0 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

: PdexPriorAuth - TTL Representation

Page standards status: Informative

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@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 -------------------------------------------------------------------

<http://hl7.org/fhir/ExplanationOfBenefit/PDexPriorAuth1> a fhir:ExplanationOfBenefit ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "PDexPriorAuth1"] ;
  fhir:Resource.meta [
     fhir:Meta.lastUpdated [ fhir:value "2024-02-06T09:14:11+00:00"^^xsd:dateTime ] ;
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization" ;
       fhir:index 0 ;
       fhir:link <http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en-US"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.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><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>LevelOfServiceCode</b>: <span title=\"Codes:{https://codesystem.x12.org/005010/1338 U}\">Urgent</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>: <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><blockquote><p><b>ReviewAction</b></p><ul><li>number: AUTH0001</li><li>http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode: <span title=\"Codes:{https://codesystem.x12.org/005010/306 A1}\">Certified in total</span></li></ul></blockquote><p><b>When Adjudicated</b>: 2024-07-23 17:26:23+0000</p><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>An attribute to express the amount of a service or item that has been utilized</b>: 1</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>"
  ] ;
  fhir:DomainResource.extension [
     fhir:index 0 ;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode" ] ;
     fhir:Extension.valueCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/1338" ] ;
         fhir:Coding.code [ fhir:value "U" ] ;
         fhir:Coding.display [ fhir:value "Urgent" ]
       ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.identifier [
     fhir:index 0 ;
     fhir:Identifier.system [ fhir:value "https://www.exampleplan.com/fhir/EOBIdentifier" ] ;
     fhir:Identifier.value [ fhir:value "PA123412341234123412341234" ]
  ] ;
  fhir:ExplanationOfBenefit.status [ fhir:value "active"] ;
  fhir:ExplanationOfBenefit.type [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/claim-type" ] ;
       fhir:Coding.code [ fhir:value "institutional" ]
     ] ;
     fhir:CodeableConcept.text [ fhir:value "Institutional" ]
  ] ;
  fhir:ExplanationOfBenefit.use [ fhir:value "preauthorization"] ;
  fhir:ExplanationOfBenefit.patient [
     fhir:link <http://hl7.org/fhir/Patient/1> ;
     fhir:Reference.reference [ fhir:value "Patient/1" ]
  ] ;
  fhir:ExplanationOfBenefit.billablePeriod [
     fhir:Period.start [ fhir:value "2021-10-01"^^xsd:date ] ;
     fhir:Period.end [ fhir:value "2021-10-31"^^xsd:date ]
  ] ;
  fhir:ExplanationOfBenefit.created [ fhir:value "2021-09-20T00:00:00+00:00"^^xsd:dateTime] ;
  fhir:ExplanationOfBenefit.insurer [
     fhir:link <http://hl7.org/fhir/Organization/Payer1> ;
     fhir:Reference.reference [ fhir:value "Organization/Payer1" ] ;
     fhir:Reference.display [ fhir:value "Example Health Plan" ]
  ] ;
  fhir:ExplanationOfBenefit.provider [
     fhir:link <http://hl7.org/fhir/Organization/Payer2> ;
     fhir:Reference.reference [ fhir:value "Organization/Payer2" ] ;
     fhir:Reference.display [ fhir:value "Another Example Health Plan" ]
  ] ;
  fhir:ExplanationOfBenefit.priority [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/processpriority" ] ;
       fhir:Coding.code [ fhir:value "normal" ] ;
       fhir:Coding.display [ fhir:value "Normal" ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.fundsReserveRequested [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/fundsreserve" ] ;
       fhir:Coding.code [ fhir:value "provider" ] ;
       fhir:Coding.display [ fhir:value "Provider" ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.fundsReserve [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/fundsreserve" ] ;
       fhir:Coding.code [ fhir:value "none" ] ;
       fhir:Coding.display [ fhir:value "None" ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.related [
     fhir:index 0 ;
     fhir:ExplanationOfBenefit.related.relationship [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship" ] ;
         fhir:Coding.code [ fhir:value "associated" ] ;
         fhir:Coding.display [ fhir:value "Associated Claim" ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.related.reference [
       fhir:Identifier.value [ fhir:value "XCLM1001" ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.outcome [ fhir:value "queued"] ;
  fhir:ExplanationOfBenefit.preAuthRefPeriod [
     fhir:index 0 ;
     fhir:Period.start [ fhir:value "2021-10-01"^^xsd:date ] ;
     fhir:Period.end [ fhir:value "2021-10-31"^^xsd:date ]
  ] ;
  fhir:ExplanationOfBenefit.careTeam [
     fhir:index 0 ;
     fhir:ExplanationOfBenefit.careTeam.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:ExplanationOfBenefit.careTeam.provider [
       fhir:link <http://hl7.org/fhir/Organization/Payer1> ;
       fhir:Reference.reference [ fhir:value "Organization/Payer1" ]
     ] ;
     fhir:ExplanationOfBenefit.careTeam.responsible [ fhir:value "true"^^xsd:boolean ]
  ] ;
  fhir:ExplanationOfBenefit.diagnosis [
     fhir:index 0 ;
     fhir:ExplanationOfBenefit.diagnosis.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:ExplanationOfBenefit.diagnosis.diagnosisCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-10-cm" ] ;
         fhir:Coding.code [ fhir:value "G89.4" ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.diagnosis.type [
       fhir:index 0 ;
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/ex-diagnosistype" ] ;
         fhir:Coding.code [ fhir:value "principal" ]
       ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.insurance [
     fhir:index 0 ;
     fhir:ExplanationOfBenefit.insurance.focal [ fhir:value "true"^^xsd:boolean ] ;
     fhir:ExplanationOfBenefit.insurance.coverage [
       fhir:link <http://hl7.org/fhir/Coverage/Coverage1> ;
       fhir:Reference.reference [ fhir:value "Coverage/Coverage1" ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.item [
     fhir:index 0 ;
     fhir:ExplanationOfBenefit.item.sequence [ fhir:value "1"^^xsd:positiveInteger ] ;
     fhir:ExplanationOfBenefit.item.category [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "https://x12.org/codes/service-type-codes" ] ;
         fhir:Coding.code [ fhir:value "3" ] ;
         fhir:Coding.display [ fhir:value "Consultation" ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.item.productOrService [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes" ] ;
         fhir:Coding.code [ fhir:value "BB201" ] ;
         fhir:Coding.display [ fhir:value "Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)" ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.item.adjudication [
       fhir:index 0 ;
       fhir:Element.id [ fhir:value "1" ] ;
       fhir:Element.extension [
         fhir:index 0 ;
         fhir:Element.extension [
           fhir:index 0 ;
           fhir:Extension.url [ fhir:value "number" ] ;
           fhir:Extension.valueString [ fhir:value "AUTH0001" ]
         ], [
           fhir:index 1 ;
           fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode" ] ;
           fhir:Extension.valueCodeableConcept [
             fhir:CodeableConcept.coding [
               fhir:index 0 ;
               fhir:Coding.system [ fhir:value "https://codesystem.x12.org/005010/306" ] ;
               fhir:Coding.code [ fhir:value "A1" ] ;
               fhir:Coding.display [ fhir:value "Certified in total" ]
             ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction" ]
       ], [
         fhir:index 1 ;
         fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated" ] ;
         fhir:Extension.valueDateTime [ fhir:value "2024-07-23T17:26:23.217+00:00"^^xsd:dateTime ]
       ] ;
       fhir:ExplanationOfBenefit.item.adjudication.category [
         fhir:CodeableConcept.coding [
           fhir:index 0 ;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/adjudication" ] ;
           fhir:Coding.code [ fhir:value "submitted" ] ;
           fhir:Coding.display [ fhir:value "Submitted Amount" ]
         ]
       ] ;
       fhir:ExplanationOfBenefit.item.adjudication.amount [
         fhir:Money.value [ fhir:value "300.99"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ]
  ] ;
  fhir:ExplanationOfBenefit.total [
     fhir:index 0 ;
     fhir:Element.extension [
       fhir:index 0 ;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization" ] ;
       fhir:Extension.valueQuantity [
         fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.total.category [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes" ] ;
         fhir:Coding.code [ fhir:value "eligible" ] ;
         fhir:Coding.display [ fhir:value "Eligible" ]
       ]
     ] ;
     fhir:ExplanationOfBenefit.total.amount [
       fhir:Money.value [ fhir:value "100"^^xsd:decimal ] ;
       fhir:Money.currency [ fhir:value "USD" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/1> a fhir:Patient .

<http://hl7.org/fhir/Organization/Payer1> a fhir:Organization .

<http://hl7.org/fhir/Organization/Payer2> a fhir:Organization .

<http://hl7.org/fhir/Coverage/Coverage1> a fhir:Coverage .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ExplanationOfBenefit/PDexPriorAuth1.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/ExplanationOfBenefit/PDexPriorAuth1.ttl> .