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

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
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• TTL

Resource Profile: PCT Advanced EOB Summary

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

Usage:

• Use this Resource Profile: PCT AEOB Bundle and PCT AEOB Packet
• Refer to this Resource Profile: PCT AEOB Composition
• Examples for this Resource Profile: ExplanationOfBenefit/PCT-AEOB-Summary-1

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Explanation of Benefit resource dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:serviceDescription	S	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children
identifier:INTER		0..*	Identifier	Intermediary System Identifier ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. ele-1: All FHIR elements must have a @value or children Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services ele-1: All FHIR elements must have a @value or children
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event. ele-1: All FHIR elements must have a @value or children
created	Σ	1..1	dateTime	The date and time this summary was generated. ele-1: All FHIR elements must have a @value or children
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim ele-1: All FHIR elements must have a @value or children
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:dataAbsentReason		1..1	(Complex)	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x]		1..1	code	Value of extension Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children Required Pattern: not-applicable
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required) ele-1: All FHIR elements must have a @value or children
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. ele-1: All FHIR elements must have a @value or children
insurance	Σ	1..*	BackboneElement	Patient insurance information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
focal	Σ	1..1	boolean	Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
Slices for total	Σ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children
total:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:memberliability	SΣ	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:eligible	SΣ	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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. ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
benefitPeriod		1..1	Period	When the benefits are applicable ele-1: All FHIR elements must have a @value or children
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required) ele-1: All FHIR elements must have a @value or children
text	SΣ	1..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required) ele-1: All FHIR elements must have a @value or children
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required) ele-1: All FHIR elements must have a @value or children
financial		1..*	BackboneElement	Benefit Summary ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:remaining	S	0..1	unsignedInt, Money	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required) ele-1: All FHIR elements must have a @value or children
Slices for allowed[x]		1..1	Money	Benefits allowed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
allowed[x]:allowedMoney		1..1	Money	Benefits allowed ele-1: All FHIR elements must have a @value or children
Slices for used[x]		1..1	Money	Benefits used Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
used[x]:usedMoney		1..1	Money	Benefits used ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.identifier:INTER.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: estimate-summary http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls 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: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern: 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

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
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
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:INTER		0..*	Identifier	Intermediary System Identifier
type		1..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
subType		0..0
use		1..1	code	claim | preauthorization | predetermination Required Pattern: predetermination
patient		1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
billablePeriod		1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created		1..1	dateTime	The date and time this summary was generated.
enterer		0..0
insurer		1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider
extension		1..*	Extension	Extension
Slices for extension				Content/Rules for all slices
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		1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
total:submitted	S	1..1	BackboneElement	Total provider submitted amount
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
total:memberliability	S	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
total:innetwork	S	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
total:outofnetwork	S	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
total:noncovered	S	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
total:negotiated	S	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
total:eligible	S	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
total:benefit	S	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
payment		0..0
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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
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
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
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:INTER		0..*	Identifier	Intermediary System Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created	Σ	1..1	dateTime	The date and time this summary was generated.
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
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 (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
Slices for total	Σ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
amount	Σ	1..1	Money	Financial total for the category
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:memberliability	SΣ	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:eligible	SΣ	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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 from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.identifier:INTER.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: estimate-summary http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype 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 from the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers 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: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms 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 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 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

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 16 elements(1 nested mandatory element)
Must-Support: 13 elements
Prohibited: 22 elements

Structures

This structure refers to these other structures:

• HRex Patient Demographics (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics)
• PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)
• PCT Coverage (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
• http://hl7.org/fhir/StructureDefinition/data-absent-reason
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit

Slices

This structure defines the following Slices:

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

Maturity: 1

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	Explanation of Benefit resource dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:serviceDescription	S	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children
identifier:INTER		0..*	Identifier	Intermediary System Identifier ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. ele-1: All FHIR elements must have a @value or children Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services ele-1: All FHIR elements must have a @value or children
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event. ele-1: All FHIR elements must have a @value or children
created	Σ	1..1	dateTime	The date and time this summary was generated. ele-1: All FHIR elements must have a @value or children
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim ele-1: All FHIR elements must have a @value or children
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:dataAbsentReason		1..1	(Complex)	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x]		1..1	code	Value of extension Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children Required Pattern: not-applicable
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required) ele-1: All FHIR elements must have a @value or children
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. ele-1: All FHIR elements must have a @value or children
insurance	Σ	1..*	BackboneElement	Patient insurance information ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
focal	Σ	1..1	boolean	Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information ele-1: All FHIR elements must have a @value or children
Slices for total	Σ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children
total:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:memberliability	SΣ	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:eligible	SΣ	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
amount	Σ	1..1	Money	Financial total for the category ele-1: All FHIR elements must have a @value or children
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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. ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
benefitPeriod		1..1	Period	When the benefits are applicable ele-1: All FHIR elements must have a @value or children
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required) ele-1: All FHIR elements must have a @value or children
text	SΣ	1..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required) ele-1: All FHIR elements must have a @value or children
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required) ele-1: All FHIR elements must have a @value or children
financial		1..*	BackboneElement	Benefit Summary ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:remaining	S	0..1	unsignedInt, Money	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required) ele-1: All FHIR elements must have a @value or children
Slices for allowed[x]		1..1	Money	Benefits allowed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
allowed[x]:allowedMoney		1..1	Money	Benefits allowed ele-1: All FHIR elements must have a @value or children
Slices for used[x]		1..1	Money	Benefits used Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
used[x]:usedMoney		1..1	Money	Benefits used ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.identifier:INTER.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: estimate-summary http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls 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: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern: 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

Differential View

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
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
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:INTER		0..*	Identifier	Intermediary System Identifier
type		1..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
subType		0..0
use		1..1	code	claim | preauthorization | predetermination Required Pattern: predetermination
patient		1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
billablePeriod		1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created		1..1	dateTime	The date and time this summary was generated.
enterer		0..0
insurer		1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider
extension		1..*	Extension	Extension
Slices for extension				Content/Rules for all slices
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		1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
total:submitted	S	1..1	BackboneElement	Total provider submitted amount
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
total:memberliability	S	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
total:innetwork	S	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
total:outofnetwork	S	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
total:noncovered	S	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
total:negotiated	S	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
total:eligible	S	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
total:benefit	S	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
payment		0..0
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
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
Slices for identifier		0..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:INTER		0..*	Identifier	Intermediary System Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: estimate-summary
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
billablePeriod	Σ	1..1	Period	The full Period of Care for all services or products included in the estimate from the first event to the last event.
created	Σ	1..1	dateTime	The date and time this summary was generated.
insurer	Σ	1..1	Reference(PCT Organization)	Party responsible for reimbursement
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
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 (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
Slices for total	Σ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
amount	Σ	1..1	Money	Financial total for the category
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:memberliability	SΣ	0..1	BackboneElement	Total member liability - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:eligible	SΣ	0..1	BackboneElement	Total eligible amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - Must include in non-zero total across all AEoBs
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible 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 from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.identifier:INTER.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	Pattern: estimate-summary http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]	required	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype 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 from the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers 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: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern: 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 from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms 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 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 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

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 16 elements(1 nested mandatory element)
Must-Support: 13 elements
Prohibited: 22 elements

Structures

This structure refers to these other structures:

• HRex Patient Demographics (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics)
• PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)
• PCT Coverage (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
• http://hl7.org/fhir/StructureDefinition/data-absent-reason
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit

Slices

This structure defines the following Slices:

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

Maturity: 1