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
<ExplanationOfBenefit xmlns="http://hl7.org/fhir">
<id value="PDexPriorAuth1"/>
<meta>
<lastUpdated value="2024-02-06T09:14:11+00:00"/>
<profile
value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization"/>
</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><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>
</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"/>
<display value="Submitted Amount"/>
</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>
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
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