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 - XML Representation

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    <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 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>
      </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>
          <extension
                     url="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated">
            <valueDateTime value="2024-07-23T17:26:23.217+00:00"/>
          </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>