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

## Example ExplanationOfBenefit: PdexPriorAuth

Page standards status: Informative

Last updated: 2024-02-06 09:14:11+0000; Language: en-US

Profile: PDex Prior Authorization

LevelOfServiceCode: Urgent

identifier: `https://www.exampleplan.com/fhir/EOBIdentifier`/PA123412341234123412341234

status: Active

type: Institutional

use: Preauthorization

patient: Johnny Appleseed Male, DoB: 1986-01-01 ( Member Number)

billablePeriod: 2021-10-01 --> 2021-10-31

created: 2021-09-20 00:00:00+0000

insurer: Example Health Plan

provider: Another Example Health Plan

priority: Normal

fundsReserveRequested: Provider

fundsReserve: None

### Relateds

- | Relationship | Reference
* | Associated Claim | XCLM1001

outcome: Queued

preAuthRefPeriod: 2021-10-01 --> 2021-10-31

### CareTeams

- | Sequence | Provider | Responsible
* | 1 | Organization Payer 1 | true

### Diagnoses

- | Sequence | Diagnosis[x] | Type
* | 1 | Chronic pain syndrome | Principal Diagnosis

### Insurances

- | Focal | Coverage
* | true | Coverage: identifier = Member Number; status = active; subscriberId = 93542106; relationship = Self

> item

> sequence: 1

> category: Consultation

> productOrService: Behavior Only, ADL Index 6 - 10/Medicare 5 day assessment (Full)

> > adjudication

> > > id

> > > 1

> > > ReviewAction

> > > - number: AUTH0001
> > > - http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode: Certified in total

> > When Adjudicated: 2024-07-23 17:26:23+0000

> > category: Submitted Amount

> > ### Amounts

> > - | Value | Currency
> > * | 300.99 | United States dollar

> total

> An attribute to express the amount of a service or item that has been utilized: 1

> category: Eligible

> ### Amounts

> - | Value | Currency
> * | 100 | United States dollar