Patient Cost Transparency Implementation Guide
2.0.0-draft - STU 2 - Draft United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Resource Profile: PCT Advanced EOB Summary

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary Version: 2.0.0-draft
Standards status: Trial-use Maturity Level: 1 Computable Name: PCTAdvancedEOBSummary
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.5

This profile is used for exchanging a summary of Explanation of Benefit (EoB) information, including costs and benefits, of all of the Advanced EoB data contained within an Advance EoB Bundle.

Usage:

Changes since version 1.1.0:

  • New Content
  • Formal Views of Profile Content

    Description of Profiles, Differentials, Snapshots and how the different presentations work.

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    ele-1: All FHIR elements must have a @value or children
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ele-1: All FHIR elements must have a @value or children
    ..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


    ele-1: All FHIR elements must have a @value or children
    ..... type Σ 1..1 CodeableConcept Description of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


    ele-1: All FHIR elements must have a @value or children
    ... type Σ 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ... use Σ 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: predetermination
    ... patient Σ 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ele-1: All FHIR elements must have a @value or children
    ... billablePeriod Σ 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ele-1: All FHIR elements must have a @value or children
    ... created Σ 1..1 dateTime The date and time this summary was generated.
    ele-1: All FHIR elements must have a @value or children
    ... insurer Σ 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ele-1: All FHIR elements must have a @value or children
    ... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ele-1: All FHIR elements must have a @value or children
    .... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: not-applicable
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ele-1: All FHIR elements must have a @value or children
    ... outcome Σ 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.


    ele-1: All FHIR elements must have a @value or children
    ... insurance Σ 1..* BackboneElement Patient insurance information
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... focal Σ 1..1 boolean Coverage to be used for adjudication
    ele-1: All FHIR elements must have a @value or children
    .... coverage Σ 1..1 Reference(PCT Coverage) Insurance information
    ele-1: All FHIR elements must have a @value or children
    ... Slices for total Σ 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    ele-1: All FHIR elements must have a @value or children
    .... total:All Slices Content/Rules for all slices
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:submitted SΣ 1..1 BackboneElement Total provider submitted amount
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:memberliability SΣ 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:innetwork SΣ 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:outofnetwork SΣ 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:noncovered SΣ 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:negotiated SΣ 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:eligible SΣ 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:benefit SΣ 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    ele-1: All FHIR elements must have a @value or children
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ele-1: All FHIR elements must have a @value or children
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ele-1: All FHIR elements must have a @value or children
    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ele-1: All FHIR elements must have a @value or children
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ele-1: All FHIR elements must have a @value or children
    .... financial 1..* BackboneElement Benefit Summary
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ele-1: All FHIR elements must have a @value or children
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ele-1: All FHIR elements must have a @value or children
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ele-1: All FHIR elements must have a @value or children
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ele-1: All FHIR elements must have a @value or children
    ...... used[x]:usedMoney 1..1 Money Benefits used
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
    http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.typeextensiblePattern: estimate-summary
    http://hl7.org/fhir/ValueSet/claim-type
    from the FHIR Standard
    ExplanationOfBenefit.userequiredPattern: predetermination
    http://hl7.org/fhir/ValueSet/claim-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]requiredPattern: not-applicable
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
    http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
    http://hl7.org/fhir/ValueSet/claim-informationcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:submitted.categoryextensiblePattern: submitted
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:memberliability.categoryextensiblePattern: memberliability
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:innetwork.categoryextensiblePattern: innetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:outofnetwork.categoryextensiblePattern: outofnetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:noncovered.categoryextensiblePattern: noncovered
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:negotiated.categoryextensiblePattern: negotiated
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:eligible.categoryextensiblePattern: eligible
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:benefit.categoryextensiblePattern: benefit
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG

    This structure is derived from ExplanationOfBenefit

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit ExplanationOfBenefit
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ..... type 1..1 CodeableConcept Description of identifier
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ... type 1..1 CodeableConcept Category or discipline
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ... subType 0..0
    ... use 1..1 code claim | preauthorization | predetermination
    Required Pattern: predetermination
    ... patient 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ... billablePeriod 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ... created 1..1 dateTime The date and time this summary was generated.
    ... enterer 0..0
    ... insurer 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ... provider
    .... extension 1..* Extension Extension
    .... Slices for extension Content/Rules for all slices
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... value[x] 1..1 code Value of extension
    Required Pattern: not-applicable
    .... reference 0..0
    .... type 0..0
    .... identifier 0..0
    .... display 0..0
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ... fundsReserveRequested 0..0
    ... fundsReserve 0..0
    ... prescription 0..0
    ... originalPrescription 0..0
    ... payee 0..0
    ... referral 0..0
    ... facility 0..0
    ... claim 0..0
    ... preAuthRef 0..0
    ... preAuthRefPeriod 0..0
    ... supportingInfo 0..0
    ... precedence 0..0
    ... insurance
    .... coverage 1..1 Reference(PCT Coverage) Insurance information
    ... item 0..0
    ... addItem 0..0
    ... adjudication 0..0
    ... Slices for total 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    .... total:All Slices Content/Rules for all slices
    ..... category S 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    .... total:submitted S 1..1 BackboneElement Total provider submitted amount
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    .... total:memberliability S 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    .... total:innetwork S 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    .... total:outofnetwork S 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    .... total:noncovered S 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    .... total:negotiated S 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    .... total:eligible S 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    .... total:benefit S 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ... payment 0..0
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    .... financial 1..* BackboneElement Benefit Summary
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Open by type:$this
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Open by type:$this
    ...... used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    ..... type Σ 1..1 CodeableConcept Description of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... system Σ 0..1 uri The namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    ..... value Σ 0..1 string The value that is unique
    Example General: 123456
    ..... period Σ 0..1 Period Time period when id is/was valid for use
    ..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
    ... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

    ... type Σ 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


    Required Pattern: At least the following
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ..... display 0..1 string Representation defined by the system
    ..... userSelected 0..1 boolean If this coding was chosen directly by the user
    .... text 0..1 string Plain text representation of the concept
    ... use Σ 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.


    Required Pattern: predetermination
    ... patient Σ 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ... billablePeriod Σ 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ... created Σ 1..1 dateTime The date and time this summary was generated.
    ... insurer Σ 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... id 0..1 id Unique id for inter-element referencing
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ... related 0..* BackboneElement Prior or corollary claims
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... claim 0..1 Reference(Claim) Reference to the related claim
    .... relationship 0..1 CodeableConcept How the reference claim is related
    Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

    .... reference 0..1 Identifier File or case reference
    ... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
    ... outcome Σ 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.

    ... disposition 0..1 string Disposition Message
    ... careTeam 0..* BackboneElement Care Team members
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Order of care team
    .... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
    .... responsible 0..1 boolean Indicator of the lead practitioner
    .... role 0..1 CodeableConcept Function within the team
    Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

    .... qualification 0..1 CodeableConcept Practitioner credential or specialization
    Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

    ... diagnosis 0..* BackboneElement Pertinent diagnosis information
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Diagnosis instance identifier
    .... diagnosis[x] 1..1 Nature of illness or problem
    Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

    ..... diagnosisCodeableConcept CodeableConcept
    ..... diagnosisReference Reference(Condition)
    .... type 0..* CodeableConcept Timing or nature of the diagnosis
    Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


    .... onAdmission 0..1 CodeableConcept Present on admission
    Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

    .... packageCode 0..1 CodeableConcept Package billing code
    Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

    ... procedure 0..* BackboneElement Clinical procedures performed
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Procedure instance identifier
    .... type 0..* CodeableConcept Category of Procedure
    Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


    .... date 0..1 dateTime When the procedure was performed
    .... procedure[x] 1..1 Specific clinical procedure
    Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

    ..... procedureCodeableConcept CodeableConcept
    ..... procedureReference Reference(Procedure)
    .... udi 0..* Reference(Device) Unique device identifier
    ... insurance Σ 1..* BackboneElement Patient insurance information
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... focal Σ 1..1 boolean Coverage to be used for adjudication
    .... coverage Σ 1..1 Reference(PCT Coverage) Insurance information
    .... preAuthRef 0..* string Prior authorization reference number
    ... accident 0..1 BackboneElement Details of the event
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... date 0..1 date When the incident occurred
    .... type 0..1 CodeableConcept The nature of the accident
    Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

    .... location[x] 0..1 Where the event occurred
    ..... locationAddress Address
    ..... locationReference Reference(Location)
    ... Slices for total Σ 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    .... total:All Slices Content/Rules for all slices
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:submitted SΣ 1..1 BackboneElement Total provider submitted amount
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:memberliability SΣ 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:innetwork SΣ 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:outofnetwork SΣ 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:noncovered SΣ 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:negotiated SΣ 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:eligible SΣ 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:benefit SΣ 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    ... formCode 0..1 CodeableConcept Printed form identifier
    Binding: Form Codes (example): The forms codes.

    ... form 0..1 Attachment Printed reference or actual form
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... number 0..1 positiveInt Note instance identifier
    .... type 0..1 code display | print | printoper
    Binding: NoteType (required): The presentation types of notes.

    .... text 0..1 string Note explanatory text
    .... language 0..1 CodeableConcept Language of the text
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    .... excluded 0..1 boolean Excluded from the plan
    .... name 0..1 string Short name for the benefit
    .... description 0..1 string Description of the benefit or services covered
    .... network 0..1 CodeableConcept In or out of network
    Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    .... financial 1..* BackboneElement Benefit Summary
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ...... used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    ExplanationOfBenefit.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
    http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.typeextensiblePattern: estimate-summary
    http://hl7.org/fhir/ValueSet/claim-type
    from the FHIR Standard
    ExplanationOfBenefit.userequiredPattern: predetermination
    http://hl7.org/fhir/ValueSet/claim-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]requiredPattern: not-applicable
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
    http://hl7.org/fhir/ValueSet/related-claim-relationship
    from the FHIR Standard
    ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
    http://hl7.org/fhir/ValueSet/payeetype
    from the FHIR Standard
    ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
    http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
    http://hl7.org/fhir/ValueSet/claim-careteamrole
    from the FHIR Standard
    ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
    http://hl7.org/fhir/ValueSet/provider-qualification
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
    http://hl7.org/fhir/ValueSet/claim-informationcategory
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
    http://hl7.org/fhir/ValueSet/claim-exception
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
    http://hl7.org/fhir/ValueSet/missing-tooth-reason
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
    http://hl7.org/fhir/ValueSet/icd-10
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosistype
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
    from the FHIR Standard
    ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
    http://hl7.org/fhir/ValueSet/ex-procedure-type
    from the FHIR Standard
    ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
    http://hl7.org/fhir/ValueSet/icd-10-procedures
    from the FHIR Standard
    ExplanationOfBenefit.accident.typeextensibleActIncidentCode
    http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
    ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
    http://hl7.org/fhir/ValueSet/service-place
    from the FHIR Standard
    ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
    http://hl7.org/fhir/ValueSet/tooth
    from the FHIR Standard
    ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
    http://hl7.org/fhir/ValueSet/surface
    from the FHIR Standard
    ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationValueCodes
    http://hl7.org/fhir/ValueSet/adjudication
    from the FHIR Standard
    ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
    http://hl7.org/fhir/ValueSet/adjudication-reason
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
    http://hl7.org/fhir/ValueSet/service-place
    from the FHIR Standard
    ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
    http://hl7.org/fhir/ValueSet/tooth
    from the FHIR Standard
    ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
    http://hl7.org/fhir/ValueSet/surface
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:submitted.categoryextensiblePattern: submitted
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:memberliability.categoryextensiblePattern: memberliability
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:innetwork.categoryextensiblePattern: innetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:outofnetwork.categoryextensiblePattern: outofnetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:noncovered.categoryextensiblePattern: noncovered
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:negotiated.categoryextensiblePattern: negotiated
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:eligible.categoryextensiblePattern: eligible
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:benefit.categoryextensiblePattern: benefit
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
    http://hl7.org/fhir/ValueSet/ex-paymenttype
    from the FHIR Standard
    ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
    http://hl7.org/fhir/ValueSet/payment-adjustment-reason
    from the FHIR Standard
    ExplanationOfBenefit.formCodeexampleForm Codes
    http://hl7.org/fhir/ValueSet/forms
    from the FHIR Standard
    ExplanationOfBenefit.processNote.typerequiredNoteType
    http://hl7.org/fhir/ValueSet/note-type|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-network
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG

    This structure is derived from ExplanationOfBenefit

    Summary

    Mandatory: 15 elements(1 nested mandatory element)
    Must-Support: 11 elements
    Prohibited: 22 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of ExplanationOfBenefit.identifier
    • The element 1 is sliced based on the value of ExplanationOfBenefit.total
    • The element 1 is sliced based on the value of ExplanationOfBenefit.benefitBalance.financial.allowed[x]
    • The element 1 is sliced based on the value of ExplanationOfBenefit.benefitBalance.financial.used[x]

    Maturity: 1

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    ele-1: All FHIR elements must have a @value or children
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ele-1: All FHIR elements must have a @value or children
    ..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


    ele-1: All FHIR elements must have a @value or children
    ..... type Σ 1..1 CodeableConcept Description of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


    ele-1: All FHIR elements must have a @value or children
    ... type Σ 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ... use Σ 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.


    ele-1: All FHIR elements must have a @value or children
    Required Pattern: predetermination
    ... patient Σ 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ele-1: All FHIR elements must have a @value or children
    ... billablePeriod Σ 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ele-1: All FHIR elements must have a @value or children
    ... created Σ 1..1 dateTime The date and time this summary was generated.
    ele-1: All FHIR elements must have a @value or children
    ... insurer Σ 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ele-1: All FHIR elements must have a @value or children
    ... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ele-1: All FHIR elements must have a @value or children
    .... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: not-applicable
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ele-1: All FHIR elements must have a @value or children
    ... outcome Σ 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.


    ele-1: All FHIR elements must have a @value or children
    ... insurance Σ 1..* BackboneElement Patient insurance information
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... focal Σ 1..1 boolean Coverage to be used for adjudication
    ele-1: All FHIR elements must have a @value or children
    .... coverage Σ 1..1 Reference(PCT Coverage) Insurance information
    ele-1: All FHIR elements must have a @value or children
    ... Slices for total Σ 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    ele-1: All FHIR elements must have a @value or children
    .... total:All Slices Content/Rules for all slices
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:submitted SΣ 1..1 BackboneElement Total provider submitted amount
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:memberliability SΣ 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:innetwork SΣ 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:outofnetwork SΣ 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:noncovered SΣ 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:negotiated SΣ 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:eligible SΣ 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    .... total:benefit SΣ 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ele-1: All FHIR elements must have a @value or children
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ..... amount Σ 1..1 Money Financial total for the category
    ele-1: All FHIR elements must have a @value or children
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    ele-1: All FHIR elements must have a @value or children
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ele-1: All FHIR elements must have a @value or children
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ele-1: All FHIR elements must have a @value or children
    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ele-1: All FHIR elements must have a @value or children
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ele-1: All FHIR elements must have a @value or children
    .... financial 1..* BackboneElement Benefit Summary
    ele-1: All FHIR elements must have a @value or children
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ele-1: All FHIR elements must have a @value or children
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ele-1: All FHIR elements must have a @value or children
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ele-1: All FHIR elements must have a @value or children
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ele-1: All FHIR elements must have a @value or children
    ...... used[x]:usedMoney 1..1 Money Benefits used
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
    http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.typeextensiblePattern: estimate-summary
    http://hl7.org/fhir/ValueSet/claim-type
    from the FHIR Standard
    ExplanationOfBenefit.userequiredPattern: predetermination
    http://hl7.org/fhir/ValueSet/claim-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]requiredPattern: not-applicable
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
    http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
    http://hl7.org/fhir/ValueSet/claim-informationcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:submitted.categoryextensiblePattern: submitted
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:memberliability.categoryextensiblePattern: memberliability
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:innetwork.categoryextensiblePattern: innetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:outofnetwork.categoryextensiblePattern: outofnetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:noncovered.categoryextensiblePattern: noncovered
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:negotiated.categoryextensiblePattern: negotiated
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:eligible.categoryextensiblePattern: eligible
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:benefit.categoryextensiblePattern: benefit
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG

    Differential View

    This structure is derived from ExplanationOfBenefit

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit ExplanationOfBenefit
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ..... type 1..1 CodeableConcept Description of identifier
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ... type 1..1 CodeableConcept Category or discipline
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ... subType 0..0
    ... use 1..1 code claim | preauthorization | predetermination
    Required Pattern: predetermination
    ... patient 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ... billablePeriod 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ... created 1..1 dateTime The date and time this summary was generated.
    ... enterer 0..0
    ... insurer 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ... provider
    .... extension 1..* Extension Extension
    .... Slices for extension Content/Rules for all slices
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... value[x] 1..1 code Value of extension
    Required Pattern: not-applicable
    .... reference 0..0
    .... type 0..0
    .... identifier 0..0
    .... display 0..0
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ... fundsReserveRequested 0..0
    ... fundsReserve 0..0
    ... prescription 0..0
    ... originalPrescription 0..0
    ... payee 0..0
    ... referral 0..0
    ... facility 0..0
    ... claim 0..0
    ... preAuthRef 0..0
    ... preAuthRefPeriod 0..0
    ... supportingInfo 0..0
    ... precedence 0..0
    ... insurance
    .... coverage 1..1 Reference(PCT Coverage) Insurance information
    ... item 0..0
    ... addItem 0..0
    ... adjudication 0..0
    ... Slices for total 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    .... total:All Slices Content/Rules for all slices
    ..... category S 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    .... total:submitted S 1..1 BackboneElement Total provider submitted amount
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    .... total:memberliability S 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    .... total:innetwork S 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    .... total:outofnetwork S 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    .... total:noncovered S 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    .... total:negotiated S 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    .... total:eligible S 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    .... total:benefit S 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ..... category 1..1 CodeableConcept Type of adjudication information
    Required Pattern: At least the following
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ... payment 0..0
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    .... financial 1..* BackboneElement Benefit Summary
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Open by type:$this
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Open by type:$this
    ...... used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... serviceDescription S 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    .... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... Slices for identifier 0..* Identifier Business Identifier for the resource
    Slice: Unordered, Open by value:type
    .... identifier:INTER 0..* Identifier Intermediary System Identifier
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    ..... type Σ 1..1 CodeableConcept Description of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: INTER
    ....... display 1..1 string Representation defined by the system
    Fixed Value: Intermediary System Identifier
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... system Σ 0..1 uri The namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    ..... value Σ 0..1 string The value that is unique
    Example General: 123456
    ..... period Σ 0..1 Period Time period when id is/was valid for use
    ..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
    ... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

    ... type Σ 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


    Required Pattern: At least the following
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: estimate-summary
    ..... display 0..1 string Representation defined by the system
    ..... userSelected 0..1 boolean If this coding was chosen directly by the user
    .... text 0..1 string Plain text representation of the concept
    ... use Σ 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.


    Required Pattern: predetermination
    ... patient Σ 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
    ... billablePeriod Σ 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ... created Σ 1..1 dateTime The date and time this summary was generated.
    ... insurer Σ 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ... provider Σ 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... id 0..1 id Unique id for inter-element referencing
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    ... priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ... related 0..* BackboneElement Prior or corollary claims
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... claim 0..1 Reference(Claim) Reference to the related claim
    .... relationship 0..1 CodeableConcept How the reference claim is related
    Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

    .... reference 0..1 Identifier File or case reference
    ... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
    ... outcome Σ 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.

    ... disposition 0..1 string Disposition Message
    ... careTeam 0..* BackboneElement Care Team members
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Order of care team
    .... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
    .... responsible 0..1 boolean Indicator of the lead practitioner
    .... role 0..1 CodeableConcept Function within the team
    Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

    .... qualification 0..1 CodeableConcept Practitioner credential or specialization
    Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

    ... diagnosis 0..* BackboneElement Pertinent diagnosis information
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Diagnosis instance identifier
    .... diagnosis[x] 1..1 Nature of illness or problem
    Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

    ..... diagnosisCodeableConcept CodeableConcept
    ..... diagnosisReference Reference(Condition)
    .... type 0..* CodeableConcept Timing or nature of the diagnosis
    Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


    .... onAdmission 0..1 CodeableConcept Present on admission
    Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

    .... packageCode 0..1 CodeableConcept Package billing code
    Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

    ... procedure 0..* BackboneElement Clinical procedures performed
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... sequence 1..1 positiveInt Procedure instance identifier
    .... type 0..* CodeableConcept Category of Procedure
    Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


    .... date 0..1 dateTime When the procedure was performed
    .... procedure[x] 1..1 Specific clinical procedure
    Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

    ..... procedureCodeableConcept CodeableConcept
    ..... procedureReference Reference(Procedure)
    .... udi 0..* Reference(Device) Unique device identifier
    ... insurance Σ 1..* BackboneElement Patient insurance information
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... focal Σ 1..1 boolean Coverage to be used for adjudication
    .... coverage Σ 1..1 Reference(PCT Coverage) Insurance information
    .... preAuthRef 0..* string Prior authorization reference number
    ... accident 0..1 BackboneElement Details of the event
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... date 0..1 date When the incident occurred
    .... type 0..1 CodeableConcept The nature of the accident
    Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

    .... location[x] 0..1 Where the event occurred
    ..... locationAddress Address
    ..... locationReference Reference(Location)
    ... Slices for total Σ 1..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category
    .... total:All Slices Content/Rules for all slices
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:submitted SΣ 1..1 BackboneElement Total provider submitted amount
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: submitted
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:memberliability SΣ 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: memberliability
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:innetwork SΣ 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: innetwork
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:outofnetwork SΣ 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: outofnetwork
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:noncovered SΣ 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: noncovered
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:negotiated SΣ 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: negotiated
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:eligible SΣ 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: eligible
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    .... total:benefit SΣ 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... category SΣ 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    Required Pattern: At least the following
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ....... id 0..1 string Unique id for inter-element referencing
    ....... extension 0..* Extension Additional content defined by implementations
    ....... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
    ....... version 0..1 string Version of the system - if relevant
    ....... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: benefit
    ....... display 0..1 string Representation defined by the system
    ....... userSelected 0..1 boolean If this coding was chosen directly by the user
    ...... text 0..1 string Plain text representation of the concept
    ..... amount Σ 1..1 Money Financial total for the category
    ... formCode 0..1 CodeableConcept Printed form identifier
    Binding: Form Codes (example): The forms codes.

    ... form 0..1 Attachment Printed reference or actual form
    ... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... number 0..1 positiveInt Note instance identifier
    .... type 0..1 code display | print | printoper
    Binding: NoteType (required): The presentation types of notes.

    .... text 0..1 string Note explanatory text
    .... language 0..1 CodeableConcept Language of the text
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... benefitPeriod 1..1 Period When the benefits are applicable
    ... benefitBalance 1..* BackboneElement Balance by Benefit Category
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    .... excluded 0..1 boolean Excluded from the plan
    .... name 0..1 string Short name for the benefit
    .... description 0..1 string Description of the benefit or services covered
    .... network 0..1 CodeableConcept In or out of network
    Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

    .... unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    .... term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    .... financial 1..* BackboneElement Benefit Summary
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ..... type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ..... Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ...... allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ..... Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ...... used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    ExplanationOfBenefit.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
    http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.typeextensiblePattern: estimate-summary
    http://hl7.org/fhir/ValueSet/claim-type
    from the FHIR Standard
    ExplanationOfBenefit.userequiredPattern: predetermination
    http://hl7.org/fhir/ValueSet/claim-use|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]requiredPattern: not-applicable
    http://hl7.org/fhir/ValueSet/data-absent-reason
    from the FHIR Standard
    ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
    http://hl7.org/fhir/ValueSet/process-priority
    from the FHIR Standard
    ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
    http://hl7.org/fhir/ValueSet/related-claim-relationship
    from the FHIR Standard
    ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
    http://hl7.org/fhir/ValueSet/payeetype
    from the FHIR Standard
    ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
    http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
    http://hl7.org/fhir/ValueSet/claim-careteamrole
    from the FHIR Standard
    ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
    http://hl7.org/fhir/ValueSet/provider-qualification
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
    http://hl7.org/fhir/ValueSet/claim-informationcategory
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
    http://hl7.org/fhir/ValueSet/claim-exception
    from the FHIR Standard
    ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
    http://hl7.org/fhir/ValueSet/missing-tooth-reason
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
    http://hl7.org/fhir/ValueSet/icd-10
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosistype
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
    from the FHIR Standard
    ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
    http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
    from the FHIR Standard
    ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
    http://hl7.org/fhir/ValueSet/ex-procedure-type
    from the FHIR Standard
    ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
    http://hl7.org/fhir/ValueSet/icd-10-procedures
    from the FHIR Standard
    ExplanationOfBenefit.accident.typeextensibleActIncidentCode
    http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
    ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
    http://hl7.org/fhir/ValueSet/service-place
    from the FHIR Standard
    ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
    http://hl7.org/fhir/ValueSet/tooth
    from the FHIR Standard
    ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
    http://hl7.org/fhir/ValueSet/surface
    from the FHIR Standard
    ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationValueCodes
    http://hl7.org/fhir/ValueSet/adjudication
    from the FHIR Standard
    ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
    http://hl7.org/fhir/ValueSet/adjudication-reason
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
    http://hl7.org/fhir/ValueSet/ex-revenue-center
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
    http://hl7.org/fhir/ValueSet/ex-benefitcategory
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
    http://hl7.org/fhir/ValueSet/ex-program-code
    from the FHIR Standard
    ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
    http://hl7.org/fhir/ValueSet/service-place
    from the FHIR Standard
    ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
    http://hl7.org/fhir/ValueSet/tooth
    from the FHIR Standard
    ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
    http://hl7.org/fhir/ValueSet/surface
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
    http://hl7.org/fhir/ValueSet/service-uscls
    from the FHIR Standard
    ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
    http://hl7.org/fhir/ValueSet/claim-modifiers
    from the FHIR Standard
    ExplanationOfBenefit.total.categoryextensiblePCTTotal
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:submitted.categoryextensiblePattern: submitted
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:memberliability.categoryextensiblePattern: memberliability
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:innetwork.categoryextensiblePattern: innetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:outofnetwork.categoryextensiblePattern: outofnetwork
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:noncovered.categoryextensiblePattern: noncovered
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:negotiated.categoryextensiblePattern: negotiated
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:eligible.categoryextensiblePattern: eligible
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.total:benefit.categoryextensiblePattern: benefit
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
    from this IG
    ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
    http://hl7.org/fhir/ValueSet/ex-paymenttype
    from the FHIR Standard
    ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
    http://hl7.org/fhir/ValueSet/payment-adjustment-reason
    from the FHIR Standard
    ExplanationOfBenefit.formCodeexampleForm Codes
    http://hl7.org/fhir/ValueSet/forms
    from the FHIR Standard
    ExplanationOfBenefit.processNote.typerequiredNoteType
    http://hl7.org/fhir/ValueSet/note-type|4.0.1
    from the FHIR Standard
    ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
    from this IG
    ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-network
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
    http://hl7.org/fhir/ValueSet/benefit-unit
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
    http://hl7.org/fhir/ValueSet/benefit-term
    from the FHIR Standard
    ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
    http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
    from this IG

    This structure is derived from ExplanationOfBenefit

    Summary

    Mandatory: 15 elements(1 nested mandatory element)
    Must-Support: 11 elements
    Prohibited: 22 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of ExplanationOfBenefit.identifier
    • The element 1 is sliced based on the value of ExplanationOfBenefit.total
    • The element 1 is sliced based on the value of ExplanationOfBenefit.benefitBalance.financial.allowed[x]
    • The element 1 is sliced based on the value of ExplanationOfBenefit.benefitBalance.financial.used[x]

    Maturity: 1

     

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