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