Notes on Fields

• .created: .created values convey the date and time the estimate was calculated, based on what was known about the state of the member’s benefits and accumulators for a given benefit period/plan year at that point in time (the .created date and time).
• The gfeReference Extension is used to point to the GFE Bundle for which the originating GFE is contained. This along with the .claim.identifier can be used to identify the originating GFE this AEOB addresses. Note that it is common for there to be a one-to-one relationship between an AEOB and a GFE, however, this is not always the case.
• .benefitPeriod: .benefitPeriod values convey the term of benefits (a.k.a. "plan year") that the benefits used to calculate the estimate were based on.
• If included, the estimate was based on the member’s benefits and accumulators for the benefit period/plan year explicitly conveyed in .benefitPeriod, as of the .created date and time.
• If not included, it is understood that the estimate was based on the member’s benefits and accumulators for the current benefit period/plan year, as of the .created date and time.
• .total.amount: Eligible amount = submitted amount - the noncovered amount - discount. The subscriber pays the member liability = deductible + coinsurance + copay + noncovered (if applicable). The eligible amount - the member liability is the potential payer's payment amount to the provider or the subscriber.
• .total.amount and .benefitbalance work together to reflect the expected member’s costs across all the Advanced EOB resources in this AEOB Packet(s). This means that all accumulations to deductible, out-of-pocket maximum, and other limits are collectively reflective of all GFEs in the GFE Packet(s), giving the Patient a comprehensive estimate for all expected service(s) or item(s) from one or more providers.
• .benefitbalance: benefit.balance shows the estimated balance by benefit category as if the expected item(s) or service(s) included in this estimate were applied. The .allowed value would reflect current allowed total limits for the specific category, unit, and term (e.g. Physical Therapy, Individual, annual.) The .used and .remaining would reflect current known balance plus or minus, respectively, the current estimate's expected item(s) or service(s) impact on the patient's benefit balance.
• total:submitted, total:memberliability, and total:eligible work together to communicate the high level summary to a patient. total:submitted is used to indicate the expected total amount submitted from the provider (charges). total:memberliability is used to indicate the expected amount the patient owes, and as stated above, the total:eligible - total:memberliability is the expected payer's payment amount.
• Working together .created values and .benefitPeriod values explicitly convey the temporal context for the state of benefits and accumulators that were used to calculate the estimate communicated in an advanced EOB. The state of a member’s benefits and accumulators for a given benefit period or the benefit period in effect may change between the date that an estimate is generated (.created) and when the services being estimated are actually rendered (e.g., the actual date of service), resulting in a difference between the estimated vs. actual cost to the member.
• The .processnote data element is used to communicate disclaimers and specific information for this estimate to the patient. Processnote should include notes to meet legislative, legal, or otherwise required disclaimers. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. Examples of the types of information payers can use the processnote for include:
  • Disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) and is subject to change.
  • Disclaimer that that coverage for such item or service is subject to a medical management technique, like prior authorization.
  • Additional information about Prior Authorization, any assumptions made such as that the estimate is calculated assuming any applicable prior auth is approved and that the estimate may be higher if approval conditions are not met. If available, Payers could include Coverage Requirements Discovery (CRD) response information for improved patient transparency and information sharing.
  • Unique assumptions about diagnosis code(s) impact on estimate accuracy, e.g. Diagnosis code was not specified. This estimate is based on assumption that this service is diagnostic and thus the patient responsibility may be higher than if the diagnosis was for preventative services.
  • Additional information indicating that the AEOB contains one or more out of network providers and thus patient responsibility may be higher than if an in-network provider was chosen.

Changes since version 1.1.0:

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Explanation of Benefit resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:serviceDescription	S	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient	Σ	1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created	Σ	1..1	dateTime	The date and time this summary was generated.
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason		1..1	(Complex)	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x]		1..1	code	Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
insurance	Σ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information
Slices for total	Σ	3..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
amount	Σ	1..1	Money	Financial total for the category
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:memberliability	SΣ	1..1	BackboneElement	Total member liability
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:eligible	SΣ	1..1	BackboneElement	Total eligible amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - 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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
processNote		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.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
benefitPeriod		1..1	Period	When the benefits are applicable
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required)
text	SΣ	1..1	string	Plain text representation of the concept
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required)
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required)
financial		1..*	BackboneElement	Benefit Summary
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:remaining	S	0..1	unsignedInt S, Money S	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x]		1..1	Money	Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney		1..1	Money	Benefits allowed
Slices for used[x]		1..1	Money	Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney		1..1	Money	Benefits used
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern Value: estimate-summary http://hl7.org/fhir/ValueSet/claim-type|4.0.1 From the FHIR Standard
ExplanationOfBenefit.use	required	Pattern Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern Value: not-applicable http://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:submitted.category	extensible	Pattern Value: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern Value: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern Value: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern Value: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern Value: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern Value: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern Value: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern Value: benefit http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.benefitBalance.category	required	PCTBenefitBalanceCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG
ExplanationOfBenefit.benefitBalance.unit	required	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	required	BenefitTermCodes http://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

Constraints

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: Bindings Constraints Obligations
ExplanationOfBenefit			ExplanationOfBenefit
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:serviceDescription	S	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
subType		0..0
use		1..1	code	claim | preauthorization | predetermination Required Pattern: predetermination
patient		1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services
billablePeriod		1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created		1..1	dateTime	The date and time this summary was generated.
enterer		0..0
insurer		1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider
extension		1..*	Extension	Extension
Slices for extension				Content/Rules for all slices
extension:dataAbsentReason		1..1	(Complex)	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x]		1..1	code	Value of extension Required Pattern: not-applicable
reference		0..0
type		0..0
identifier		0..0
display		0..0
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested		0..0
fundsReserve		0..0
prescription		0..0
originalPrescription		0..0
payee		0..0
referral		0..0
facility		0..0
claim		0..0
preAuthRef		0..0
preAuthRefPeriod		0..0
supportingInfo		0..0
precedence		0..0
insurance
coverage		1..1	Reference(PCT Coverage)	Insurance information
item		0..0
addItem		0..0
adjudication		0..0
Slices for total		3..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
total:submitted	S	1..1	BackboneElement	Total provider submitted amount
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
total:memberliability	S	1..1	BackboneElement	Total member liability
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
total:eligible	S	1..1	BackboneElement	Total eligible amount
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
total:innetwork	S	0..1	BackboneElement	Total in network amount - only include when total type is applicable
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
total:outofnetwork	S	0..1	BackboneElement	Total out of network amount - only include when total type is applicable
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
total:noncovered	S	0..1	BackboneElement	Total noncovered amount - only include when total type is applicable
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
total:negotiated	S	0..1	BackboneElement	Total negotiated amount - 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
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
total:benefit	S	0..1	BackboneElement	Total benefit amount - only include when total type is applicable
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
payment		0..0
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
benefitPeriod		1..1	Period	When the benefits are applicable
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required)
text	S	1..1	string	Plain text representation of the concept
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required)
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required)
financial		1..*	BackboneElement	Benefit Summary
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:remaining	S	0..1	unsignedInt S, Money S	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x]		1..1	Money	Benefits allowed Slice: Unordered, Open by type:$this
allowed[x]:allowedMoney		1..1	Money	Benefits allowed
Slices for used[x]		1..1	Money	Benefits used Slice: Unordered, Open by type:$this
used[x]:usedMoney		1..1	Money	Benefits used
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.benefitBalance.category	required	PCTBenefitBalanceCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG
ExplanationOfBenefit.benefitBalance.unit	required	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	required	BenefitTermCodes http://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: Bindings Constraints Obligations
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Explanation of Benefit resource
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		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
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:serviceDescription	S	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for the resource
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient	Σ	1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created	Σ	1..1	dateTime	The date and time this summary was generated.
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason		1..1	(Complex)	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id		0..1	id	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x]		1..1	code	Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
careTeam		0..*	BackboneElement	Care Team members
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	Σ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
Slices for total	Σ	3..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
amount	Σ	1..1	Money	Financial total for the category
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:memberliability	SΣ	1..1	BackboneElement	Total member liability
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:eligible	SΣ	1..1	BackboneElement	Total eligible amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - only include when total type is applicable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - only include when total type is applicable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - only include when total type is applicable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - 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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - only include when total type is applicable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
benefitPeriod		1..1	Period	When the benefits are applicable
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
text	SΣ	1..1	string	Plain text representation of the concept
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required)
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required)
financial		1..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:remaining	S	0..1	unsignedInt S, Money S	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x]		1..1	Money	Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney		1..1	Money	Benefits allowed
Slices for used[x]		1..1	Money	Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney		1..1	Money	Benefits used
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages|4.0.1 From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern Value: estimate-summary http://hl7.org/fhir/ValueSet/claim-type|4.0.1 From the FHIR Standard
ExplanationOfBenefit.use	required	Pattern Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern Value: not-applicable http://hl7.org/fhir/ValueSet/data-absent-reason From the FHIR Standard
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard
ExplanationOfBenefit.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1 From the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype|4.0.1 From the FHIR Standard
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ExplanationOfBenefit.careTeam.role	example	ClaimCareTeamRoleCodes http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1 From the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification|4.0.1 From the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1 From the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception|4.0.1 From the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1 From the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10|4.0.1 From the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1 From the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1 From the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1 From the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1 From the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1 From the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 From the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 From the FHIR Standard
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:submitted.category	extensible	Pattern Value: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern Value: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern Value: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern Value: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern Value: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern Value: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern Value: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern Value: benefit http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1 From the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1 From the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms|4.0.1 From the FHIR Standard
ExplanationOfBenefit.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ExplanationOfBenefit.processNote.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages|4.0.1 From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.category	required	PCTBenefitBalanceCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG
ExplanationOfBenefit.benefitBalance.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network|4.0.1 From the FHIR Standard
ExplanationOfBenefit.benefitBalance.unit	required	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	required	BenefitTermCodes http://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

Constraints

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()