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 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary | Version: 2.0.0 | |||
Standards status: Trial-use | Maturity Level: 1 | Computable Name: PCTAdvancedEOBSummary | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.5 |
This profile is used for exchanging a summary of Advanced Explanation of Benefit (AEOB) information, including costs and benefits, of all of the Advanced EOB data contained within an AEOB Packet.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 1.1.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination |
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Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services |
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Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. |
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Σ | 1..1 | dateTime | The date and time this summary was generated. |
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement |
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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0..0 | |||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
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Σ | 1..* | BackboneElement | Patient insurance information |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | boolean | Coverage to be used for adjudication |
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
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Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category |
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Content/Rules for all slices | |||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total provider submitted amount |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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SΣ | 1..1 | string | Plain text representation of the concept |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.type | extensible | Pattern Value: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern Value: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:submitted.category | extensible | Pattern Value: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern Value: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:eligible.category | extensible | Pattern Value: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern Value: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern Value: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern Value: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern Value: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:benefit.category | extensible | Pattern Value: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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ExplanationOfBenefit | |||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..0 | |||
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1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
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1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
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1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. | |
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1..1 | dateTime | The date and time this summary was generated. | |
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0..0 | |||
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1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
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1..* | Extension | Extension | |
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Content/Rules for all slices | |||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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1..1 | code | Value of extension Required Pattern: not-applicable | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | Reference(PCT Coverage) | Insurance information | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | |
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Content/Rules for all slices | |||
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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S | 1..1 | BackboneElement | Total provider submitted amount |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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S | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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S | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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S | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..0 | |||
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1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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S | 1..1 | string | Plain text representation of the concept |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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0..* | Identifier | Business Identifier for the resource | |||||
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
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Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | ||||
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Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. | ||||
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Σ | 1..1 | dateTime | The date and time this summary was generated. | ||||
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
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0..1 | id | Unique id for inter-element referencing | |||||
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0..0 | |||||||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | BackboneElement | Care Team members | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
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0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
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0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Pertinent diagnosis information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Diagnosis instance identifier | |||||
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1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
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CodeableConcept | |||||||
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Reference(Condition) | |||||||
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0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
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0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Procedure instance identifier | |||||
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0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
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0..1 | dateTime | When the procedure was performed | |||||
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1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
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Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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Σ | 1..* | BackboneElement | Patient insurance information | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | BackboneElement | Details of the event | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | date | When the incident occurred | |||||
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0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc. | |||||
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0..1 | Where the event occurred | ||||||
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Address | |||||||
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Reference(Location) | |||||||
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Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
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Σ | 1..1 | Money | Financial total for the category | ||||
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SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
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0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
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0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
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0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
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0..1 | Attachment | Printed reference or actual form | |||||
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1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | positiveInt | Note instance identifier | |||||
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0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Note explanatory text | |||||
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0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
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1..1 | Period | When the benefits are applicable | |||||
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1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Plain text representation of the concept | ||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
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0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
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1..* | BackboneElement | Benefit Summary | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits allowed | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits used | |||||
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Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.type | extensible | Pattern Value: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern Value: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship From the FHIR Standard | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole From the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup From the FHIR Standard | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type From the FHIR Standard | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures From the FHIR Standard | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0 | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place From the FHIR Standard | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth From the FHIR Standard | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface From the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:submitted.category | extensible | Pattern Value: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern Value: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:eligible.category | extensible | Pattern Value: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern Value: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern Value: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern Value: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern Value: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:benefit.category | extensible | Pattern Value: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard | ||||
ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms From the FHIR Standard | ||||
ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 17 elements
Must-Support: 13 elements
Prohibited: 22 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination |
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Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services |
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Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. |
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Σ | 1..1 | dateTime | The date and time this summary was generated. |
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement |
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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0..0 | |||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
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Σ | 1..* | BackboneElement | Patient insurance information |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | boolean | Coverage to be used for adjudication |
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
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Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category |
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Content/Rules for all slices | |||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total provider submitted amount |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | Money | Financial total for the category |
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1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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SΣ | 1..1 | string | Plain text representation of the concept |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.type | extensible | Pattern Value: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern Value: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:submitted.category | extensible | Pattern Value: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern Value: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:eligible.category | extensible | Pattern Value: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern Value: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern Value: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern Value: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern Value: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.total:benefit.category | extensible | Pattern Value: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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ExplanationOfBenefit | |||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
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1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |
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0..0 | |||
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1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination | |
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1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
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1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. | |
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1..1 | dateTime | The date and time this summary was generated. | |
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0..0 | |||
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1..1 | Reference(PCT Organization) | Party responsible for reimbursement | |
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1..* | Extension | Extension | |
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Content/Rules for all slices | |||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
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1..1 | code | Value of extension Required Pattern: not-applicable | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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0..0 | |||
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1..1 | Reference(PCT Coverage) | Insurance information | |
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0..0 | |||
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0..0 | |||
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0..0 | |||
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3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | |
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Content/Rules for all slices | |||
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
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S | 1..1 | BackboneElement | Total provider submitted amount |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
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S | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
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S | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
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S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
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S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
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S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
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S | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
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S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
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0..0 | |||
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1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
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1..1 | Period | When the benefits are applicable | |
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1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |
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1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
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S | 1..1 | string | Plain text representation of the concept |
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
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1..* | BackboneElement | Benefit Summary | |
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit |
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |
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1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits allowed | |
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1..1 | Money | Benefits used Slice: Unordered, Open by type:$this | |
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1..1 | Money | Benefits used | |
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Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
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S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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0..* | Identifier | Business Identifier for the resource | |||||
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination | ||||
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Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | ||||
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Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event. | ||||
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Σ | 1..1 | dateTime | The date and time this summary was generated. | ||||
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Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |||||
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0..1 | id | Unique id for inter-element referencing | |||||
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0..0 | |||||||
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1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |||||
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1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | BackboneElement | Care Team members | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Indicator of the lead practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Pertinent diagnosis information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Diagnosis instance identifier | |||||
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1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
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CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Condition) | |||||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Procedure instance identifier | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | When the procedure was performed | |||||
![]() ![]() ![]() ![]() |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Procedure) | |||||||
![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() |
Σ | 1..* | BackboneElement | Patient insurance information | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
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Σ | 1..1 | Reference(PCT Coverage) | Insurance information | ||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | BackboneElement | Details of the event | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | date | When the incident occurred | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | Where the event occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
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Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category | ||||
![]() ![]() ![]() ![]() |
Content/Rules for all slices | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
![]() ![]() ![]() |
0..1 | Attachment | Printed reference or actual form | |||||
![]() ![]() ![]() |
1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | positiveInt | Note instance identifier | |||||
![]() ![]() ![]() ![]() |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Note explanatory text | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
1..1 | Period | When the benefits are applicable | |||||
![]() ![]() ![]() |
1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Plain text representation of the concept | ||||
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0..1 | boolean | Excluded from the plan | |||||
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0..1 | string | Short name for the benefit | |||||
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0..1 | string | Description of the benefit or services covered | |||||
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0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
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1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
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1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
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1..* | BackboneElement | Benefit Summary | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
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S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit | ||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required) | |||||
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1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits allowed | |||||
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1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this | |||||
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1..1 | Money | Benefits used | |||||
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Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
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ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.type | extensible | Pattern Value: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern Value: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship From the FHIR Standard | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole From the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception From the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission From the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup From the FHIR Standard | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type From the FHIR Standard | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures From the FHIR Standard | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0 | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place From the FHIR Standard | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth From the FHIR Standard | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface From the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard | ||||
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:submitted.category | extensible | Pattern Value: submittedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:memberliability.category | extensible | Pattern Value: memberliabilityhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:eligible.category | extensible | Pattern Value: eligiblehttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:innetwork.category | extensible | Pattern Value: innetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:outofnetwork.category | extensible | Pattern Value: outofnetworkhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:noncovered.category | extensible | Pattern Value: noncoveredhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:negotiated.category | extensible | Pattern Value: negotiatedhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.total:benefit.category | extensible | Pattern Value: benefithttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard | ||||
ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms From the FHIR Standard | ||||
ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS(a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 17 elements
Must-Support: 13 elements
Prohibited: 22 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron