Da Vinci Payer Data Exchange
2.1.1 - STU 2.1

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 2.1.1 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" : "extensions",
        "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>"
      },
      "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"
          }
        }
      ]
    }