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Scope package:hl7.fhir.us.davinci-pdex@2.0.0
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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"
        }
    }
]
}