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
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints![]() |
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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 | |
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?!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 |
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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 | |
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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 |
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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 |
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?! | 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 |
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children | |
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0..* | Identifier | Intermediary System Identifier ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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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 |
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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 |
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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 |
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Σ | 1..1 | dateTime | The date and time this summary was generated. ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim ele-1: All FHIR elements must have a @value or children |
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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 | |
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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 | |
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0..0 | |||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
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1..1 | code | Value of extension Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children Required Pattern: not-applicable | |
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) ele-1: All FHIR elements must have a @value or children | |
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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 |
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Σ | 1..* | BackboneElement | Patient insurance information ele-1: All FHIR elements must have a @value or children |
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?!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 |
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Σ | 1..1 | boolean | Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information ele-1: All FHIR elements must have a @value or children |
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Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children |
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Content/Rules for all slices | |||
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?!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 |
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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 |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | BackboneElement | Total provider submitted amount ele-1: All FHIR elements must have a @value or children |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 | |
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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 | |
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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 | |
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?!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 |
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1..1 | Period | When the benefits are applicable ele-1: All FHIR elements must have a @value or children | |
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1..* | BackboneElement | Balance by Benefit Category ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) ele-1: All FHIR elements must have a @value or children | |
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1..* | BackboneElement | Benefit Summary ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits allowed ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits used ele-1: All FHIR elements must have a @value or children | |
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Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier:INTER.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier")http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | extensible | Pattern: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:submitted.category | extensible | Pattern: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:eligible.category | extensible | Pattern: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:benefit.category | extensible | Pattern: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (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
Name | Flags | Card. | Type | Description & Constraints![]() |
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ExplanationOfBenefit | |||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |
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0..* | Identifier | Intermediary System Identifier | |
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1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..0 | |||
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1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
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1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | |
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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. | |
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1..1 | dateTime | The date and time this summary was generated. | |
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0..0 | |||
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1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
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1..* | Extension | Extension | |
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Content/Rules for all slices | |||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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1..1 | code | Value of extension Required Pattern: not-applicable | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | Reference(PCT Coverage) | Insurance information | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | |
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Content/Rules for all slices | |||
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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S | 1..1 | BackboneElement | Total provider submitted amount |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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S | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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S | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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S | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..0 | |||
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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. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Balance by Benefit Category | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS from this IG |
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
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0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |||||
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0..* | Identifier | Intermediary System Identifier | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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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 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
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Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | ||||
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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. | ||||
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Σ | 1..1 | dateTime | The date and time this summary was generated. | ||||
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
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0..1 | id | Unique id for inter-element referencing | |||||
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0..0 | |||||||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | BackboneElement | Care Team members | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
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0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
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0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Pertinent diagnosis information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Diagnosis instance identifier | |||||
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1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
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CodeableConcept | |||||||
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Reference(Condition) | |||||||
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0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
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0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Procedure instance identifier | |||||
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0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
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0..1 | dateTime | When the procedure was performed | |||||
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1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
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Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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Σ | 1..* | BackboneElement | Patient insurance information | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | BackboneElement | Details of the event | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | date | When the incident occurred | |||||
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0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
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0..1 | Where the event occurred | ||||||
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Address | |||||||
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Reference(Location) | |||||||
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Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
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Σ | 1..1 | Money | Financial total for the category | ||||
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SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
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0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
![]() ![]() ![]() |
0..1 | Attachment | Printed reference or actual form | |||||
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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. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | positiveInt | Note instance identifier | |||||
![]() ![]() ![]() ![]() |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Note explanatory text | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
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1..1 | Period | When the benefits are applicable | |||||
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1..* | BackboneElement | Balance by Benefit Category | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
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1..* | BackboneElement | Benefit Summary | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits allowed | |||||
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits used | |||||
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Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
ExplanationOfBenefit.identifier:INTER.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier")http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.type | extensible | Pattern: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:submitted.category | extensible | Pattern: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:eligible.category | extensible | Pattern: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:benefit.category | extensible | Pattern: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | ||||
ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (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:
Maturity: 1
Key Elements View
Name | Flags | Card. | Type | Description & Constraints![]() |
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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 | |
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?!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 |
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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 | |
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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 |
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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 |
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?! | 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 |
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children | |
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0..* | Identifier | Intermediary System Identifier ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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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 |
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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 |
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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 |
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Σ | 1..1 | dateTime | The date and time this summary was generated. ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim ele-1: All FHIR elements must have a @value or children |
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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 | |
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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 | |
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0..0 | |||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
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1..1 | code | Value of extension Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children Required Pattern: not-applicable | |
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) ele-1: All FHIR elements must have a @value or children | |
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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 |
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Σ | 1..* | BackboneElement | Patient insurance information ele-1: All FHIR elements must have a @value or children |
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?!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 |
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Σ | 1..1 | boolean | Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information ele-1: All FHIR elements must have a @value or children |
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Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children |
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Content/Rules for all slices | |||
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?!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 |
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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 |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | BackboneElement | Total provider submitted amount ele-1: All FHIR elements must have a @value or children |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
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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 | |
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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 | |
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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 | |
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?!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 |
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1..1 | Period | When the benefits are applicable ele-1: All FHIR elements must have a @value or children | |
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1..* | BackboneElement | Balance by Benefit Category ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) ele-1: All FHIR elements must have a @value or children | |
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1..* | BackboneElement | Benefit Summary ele-1: All FHIR elements must have a @value or children | |
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?!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 |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits allowed ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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1..1 | Money | Benefits used ele-1: All FHIR elements must have a @value or children | |
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Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier:INTER.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier")http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | extensible | Pattern: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:submitted.category | extensible | Pattern: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:eligible.category | extensible | Pattern: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:benefit.category | extensible | Pattern: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (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
Name | Flags | Card. | Type | Description & Constraints![]() |
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ExplanationOfBenefit | |||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |
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0..* | Identifier | Intermediary System Identifier | |
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1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..0 | |||
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1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
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1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | |
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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. | |
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1..1 | dateTime | The date and time this summary was generated. | |
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0..0 | |||
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1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
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1..* | Extension | Extension | |
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Content/Rules for all slices | |||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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1..1 | code | Value of extension Required Pattern: not-applicable | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | Reference(PCT Coverage) | Insurance information | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | |
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Content/Rules for all slices | |||
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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S | 1..1 | BackboneElement | Total provider submitted amount |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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S | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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S | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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S | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..0 | |||
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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. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Balance by Benefit Category | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS from this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |||||
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0..* | Identifier | Intermediary System Identifier | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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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 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
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1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
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Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | ||||
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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. | ||||
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Σ | 1..1 | dateTime | The date and time this summary was generated. | ||||
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
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0..1 | id | Unique id for inter-element referencing | |||||
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0..0 | |||||||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | BackboneElement | Care Team members | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
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0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Pertinent diagnosis information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Diagnosis instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Condition) | |||||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Procedure instance identifier | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | When the procedure was performed | |||||
![]() ![]() ![]() ![]() |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Procedure) | |||||||
![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() |
Σ | 1..* | BackboneElement | Patient insurance information | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
![]() ![]() ![]() ![]() |
0..* | string | Prior authorization reference number | |||||
![]() ![]() ![]() |
0..1 | BackboneElement | Details of the event | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | date | When the incident occurred | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | Where the event occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
![]() ![]() ![]() |
Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | ||||
![]() ![]() ![]() ![]() |
Content/Rules for all slices | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
![]() ![]() ![]() |
0..1 | Attachment | Printed reference or actual form | |||||
![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | positiveInt | Note instance identifier | |||||
![]() ![]() ![]() ![]() |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Note explanatory text | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
1..1 | Period | When the benefits are applicable | |||||
![]() ![]() ![]() |
1..* | BackboneElement | Balance by Benefit Category | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
![]() ![]() ![]() ![]() |
1..* | BackboneElement | Benefit Summary | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits allowed | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits used | |||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
ExplanationOfBenefit.identifier:INTER.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier")http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.type | extensible | Pattern: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:submitted.category | extensible | Pattern: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:eligible.category | extensible | Pattern: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:benefit.category | extensible | Pattern: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | ||||
ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (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:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron