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-ballot 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 | Version: 2.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 2 | Computable Name: PCTAdvancedEOB | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.6 |
The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |
type | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) | |
use | 1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
patient | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | |
created | 1..1 | dateTime | The date and time this estimate was calculated. | |
insurer | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
provider | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim | |
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) |
claim | 1..1 | Reference(Claim) | Claim reference | |
identifier | 1..1 | Identifier | GFE identifier of the originally submitted claim | |
system | S | 0..1 | uri | The namespace for the identifier value |
value | 1..1 | string | The value that is unique | |
insurance | ||||
coverage | 1..1 | Reference(PCT Coverage) | Insurance information | |
item | 1..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
serviced[x] | 1..1 | date, Period | This is the planned or estimated date(s)s of service | |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
amount | 0..0 | |||
value | 0..0 | |||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
amount | 0..0 | |||
value | 0..0 | |||
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for total | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
total:submitted | S | 1..1 | BackboneElement | Total provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
total:memberliability | S | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
total:innetwork | S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
total:outofnetwork | S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
total:noncovered | S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
total:negotiated | S | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
total:eligible | S | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
total:benefit | S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
allowed[x] | S | 1..1 | Benefits allowed | |
allowedUnsignedInt | unsignedInt S | |||
allowedMoney | Money S | |||
used[x] | S | 1..1 | Benefits used | |
usedUnsignedInt | unsignedInt S | |||
usedMoney | Money S | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.type | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.item.revenue | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | |
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination |
patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated. |
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement |
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim |
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) |
claim | 1..1 | Reference(Claim) | Claim reference | |
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | Σ | 1..1 | string | The value that is unique Example General: 123456 |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
item | 1..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Item instance identifier | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
serviced[x] | 1..1 | This is the planned or estimated date(s)s of service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for total | Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
amount | Σ | 1..1 | Money | Financial total for the category |
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
amount | Σ | 1..1 | Money | Financial total for the category |
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
remaining | S | 0..1 | unsignedInt, Money | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
allowed[x] | S | 1..1 | Benefits allowed | |
allowedUnsignedInt | unsignedInt | |||
allowedMoney | Money | |||
used[x] | S | 1..1 | Benefits used | |
usedUnsignedInt | unsignedInt | |||
usedMoney | Money | |||
Documentation for this format |
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.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uc("Unique Claim ID")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 | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | |
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.item.revenue | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | |
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.item.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.item.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | example | Pattern: renderingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:innetwork.category | example | Pattern: innetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:outofnetwork.category | example | Pattern: outofnetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:noncovered.category | example | Pattern: noncoveredhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:negotiated.category | example | Pattern: negotiatedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |||||
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |||||
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated. | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim | ||||
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | ||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
related | 0..* | BackboneElement | Prior or corollary claims | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
reference | 0..1 | Identifier | File or case reference | |||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
facility | 0..1 | Reference(Location) | Servicing Facility | |||||
claim | 1..1 | Reference(Claim) | Claim reference | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..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. | ||||
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
supportingInfo | 0..* | BackboneElement | Supporting information | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Resource) | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 1..* | BackboneElement | Patient insurance information | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 0..1 | BackboneElement | Details of the event | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
date | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
item | 1..* | BackboneElement | Product or service provided | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |||||
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) | ||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 1..1 | This is the planned or estimated date(s)s of service | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | S | 0..1 | SimpleQuantity | Count of products or services | ||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
detail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
addItem | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 0..* | positiveInt | Item sequence number | |||||
detailSequence | 0..* | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
detail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
subDetail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
Slices for total | Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | ||||
total:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
form | 0..1 | Attachment | Printed reference or actual form | |||||
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 1..1 | Period | When the benefits are applicable | |||||
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
financial | 1..* | BackboneElement | Benefit Summary | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
allowed[x] | S | 1..1 | Benefits allowed | |||||
allowedUnsignedInt | unsignedInt S | |||||||
allowedMoney | Money S | |||||||
used[x] | S | 1..1 | Benefits used | |||||
usedUnsignedInt | unsignedInt S | |||||||
usedMoney | Money S | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguages
http://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.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uc("Unique Claim ID")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 | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | ||||
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve 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.claim.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
ExplanationOfBenefit.claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.claim.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type 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 | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | ||||
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | ||||
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 | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:medicalmanagement.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | ||||
ExplanationOfBenefit.item.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:submitted.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:memberliability.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:eligible.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefit.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.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | ||||
ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:medicalmanagement.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | example | Pattern: renderingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | ||||
ExplanationOfBenefit.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:submitted.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:memberliability.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:eligible.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefit.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:innetwork.category | example | Pattern: innetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:outofnetwork.category | example | Pattern: outofnetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:noncovered.category | example | Pattern: noncoveredhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:negotiated.category | example | Pattern: negotiatedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
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 | CommonLanguages
http://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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 21 elements(5 nested mandatory elements)
Must-Support: 37 elements
Prohibited: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |
type | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) | |
use | 1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
patient | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | |
created | 1..1 | dateTime | The date and time this estimate was calculated. | |
insurer | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
provider | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim | |
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) |
claim | 1..1 | Reference(Claim) | Claim reference | |
identifier | 1..1 | Identifier | GFE identifier of the originally submitted claim | |
system | S | 0..1 | uri | The namespace for the identifier value |
value | 1..1 | string | The value that is unique | |
insurance | ||||
coverage | 1..1 | Reference(PCT Coverage) | Insurance information | |
item | 1..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
serviced[x] | 1..1 | date, Period | This is the planned or estimated date(s)s of service | |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
amount | 0..0 | |||
value | 0..0 | |||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
amount | 0..0 | |||
value | 0..0 | |||
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for total | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
total:submitted | S | 1..1 | BackboneElement | Total provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
total:memberliability | S | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
total:innetwork | S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
total:outofnetwork | S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
total:noncovered | S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
total:negotiated | S | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
total:eligible | S | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
total:benefit | S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
allowed[x] | S | 1..1 | Benefits allowed | |
allowedUnsignedInt | unsignedInt S | |||
allowedMoney | Money S | |||
used[x] | S | 1..1 | Benefits used | |
usedUnsignedInt | unsignedInt S | |||
usedMoney | Money S | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.type | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.item.revenue | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | |
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination |
patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated. |
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement |
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim |
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) |
claim | 1..1 | Reference(Claim) | Claim reference | |
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | Σ | 1..1 | string | The value that is unique Example General: 123456 |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
item | 1..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Item instance identifier | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) |
serviced[x] | 1..1 | This is the planned or estimated date(s)s of service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
Slices for total | Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
amount | Σ | 1..1 | Money | Financial total for the category |
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
amount | Σ | 1..1 | Money | Financial total for the category |
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
remaining | S | 0..1 | unsignedInt, Money | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
allowed[x] | S | 1..1 | Benefits allowed | |
allowedUnsignedInt | unsignedInt | |||
allowedMoney | Money | |||
used[x] | S | 1..1 | Benefits used | |
usedUnsignedInt | unsignedInt | |||
usedMoney | Money | |||
Documentation for this format |
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.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uc("Unique Claim ID")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 | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | |
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.item.revenue | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | |
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.item.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.item.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | |
ExplanationOfBenefit.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | example | Pattern: renderingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | |
ExplanationOfBenefit.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:innetwork.category | example | Pattern: innetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:outofnetwork.category | example | Pattern: outofnetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:noncovered.category | example | Pattern: noncoveredhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:negotiated.category | example | Pattern: negotiatedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
gfeReference | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference | |||||
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |||||
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
identifier:uniqueclaimid | 1..1 | Identifier | Unique Claim ID | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Unique Claim ID | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: PCT Advance Explanation of Benefit Type Value Set (required) | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
patient | Σ | 1..1 | Reference(HRex Patient Demographics) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated. | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim | ||||
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | ||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
related | 0..* | BackboneElement | Prior or corollary claims | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
reference | 0..1 | Identifier | File or case reference | |||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
facility | 0..1 | Reference(Location) | Servicing Facility | |||||
claim | 1..1 | Reference(Claim) | Claim reference | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..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. | ||||
system | SΣ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
supportingInfo | 0..* | BackboneElement | Supporting information | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Resource) | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 1..* | BackboneElement | Patient insurance information | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 0..1 | BackboneElement | Details of the event | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
date | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
item | 1..* | BackboneElement | Product or service provided | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
serviceDescription | SC | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) | |||||
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) | ||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 1..1 | This is the planned or estimated date(s)s of service | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | S | 0..1 | SimpleQuantity | Count of products or services | ||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
detail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
addItem | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 0..* | positiveInt | Item sequence number | |||||
detailSequence | 0..* | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
detail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
subDetail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
subjectToMedicalMgmt | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
Slices for total | Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | ||||
total:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
form | 0..1 | Attachment | Printed reference or actual form | |||||
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 1..1 | Period | When the benefits are applicable | |||||
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
financial | 1..* | BackboneElement | Benefit Summary | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
allowed[x] | S | 1..1 | Benefits allowed | |||||
allowedUnsignedInt | unsignedInt S | |||||||
allowedMoney | Money S | |||||||
used[x] | S | 1..1 | Benefits used | |||||
usedUnsignedInt | unsignedInt S | |||||||
usedMoney | Money S | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguages
http://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.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uc("Unique Claim ID")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 | required | PCTAEOBTypeVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG | ||||
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve 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.claim.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
ExplanationOfBenefit.claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.claim.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type 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 | required | PCTGFEItemRevenueVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS from this IG | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | required | USClaimMedicalProductOrServiceCodeshttp://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes from this IG | ||||
ExplanationOfBenefit.item.modifier | required | PCTGFEItemCptHcpcsVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS from this IG | ||||
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 | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:medicalmanagement.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | ||||
ExplanationOfBenefit.item.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:submitted.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:memberliability.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:eligible.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication:benefit.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.adjudication.category | extensible | PCTAdjudicationCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG | ||||
ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:medicalmanagement.category | example | Pattern: medicalmanagementhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:medicalmanagement.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | example | Pattern: renderingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | PCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS from this IG | ||||
ExplanationOfBenefit.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | PCTAdjustmentReasonVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG | ||||
ExplanationOfBenefit.adjudication:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:submitted.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:memberliability.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:eligible.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.adjudication:benefit.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | ||||
ExplanationOfBenefit.total:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:innetwork.category | example | Pattern: innetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:outofnetwork.category | example | Pattern: outofnetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:noncovered.category | example | Pattern: noncoveredhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:negotiated.category | example | Pattern: negotiatedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.total:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
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 | CommonLanguages
http://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 |
Id | Grade | Path(s) | Details | Requirements |
pct-aeob-1 | error | ExplanationOfBenefit | Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) : extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() | |
pct-aeob-2 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() | |
pct-aeob-3 | error | ExplanationOfBenefit | Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) : adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 21 elements(5 nested mandatory elements)
Must-Support: 37 elements
Prohibited: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pct#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-11-20
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