FHIR IG analytics| Package | hl7.fhir.us.davinci-pdex |
| Resource Type | ExplanationOfBenefit |
| Id | ExplanationOfBenefit-PDexPriorAuth1.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: ExplanationOfBenefit PDexPriorAuth1
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
| Relationship | Reference |
| Associated Claim | XCLM1001 |
outcome: Queued
preAuthRefPeriod: 2021-10-01 --> 2021-10-31
| Sequence | Provider | Responsible |
| 1 | Organization Payer 1 | true |
| Sequence | Diagnosis[x] | Type |
| 1 | Chronic pain syndrome | Principal Diagnosis |
| 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
1ReviewAction
- 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
FHIR
FHIRsmith{
"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": "<!-- snip (see above) -->"
},
"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"
}
}
]
}