| 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 |
| value |
| 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 |
| diagnosis |
| 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 |
| value : AUTH0001 |
| extension |
| url : http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewActionCode |
| value |
| 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 |
| value |
| value : 1 |
| category |
| coding |
| system : http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PriorAuthorizationValueCodes |
| code : eligible |
| display : Eligible |
| amount |
| value : 100 |
| currency : USD |