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{
"
resourceType
"
:
"
ExplanationOfBenefit
"
,
"
id
"
:
"
PDexPriorAuth1
"
,
"
meta
"
:
{
"
lastUpdated
"
:
"
2021-10-12T09:14:11+00:00
"
,
"
profile
"
:
[
"
http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0
"
]
}
,
"
language
"
:
"
en-US
"
,
"
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
"
:
"
http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
"
,
"
code
"
:
"
J0222
"
,
"
display
"
:
"
Patisiran
"
}
]
}
,
"
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
"
}
]
,
"
category
"
:
{
"
coding
"
:
[
{
"
system
"
:
"
http://terminology.hl7.org/CodeSystem/adjudication
"
,
"
code
"
:
"
submitted
"
}
]
}
,
"
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
"
}
}
]
}