Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary | Version: 2.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 1 | Computable Name: PCTAdvancedEOBSummary | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.5 |
This profile is used for exchanging a summary of Explanation of Benefit (EoB) information, including costs and benefits, of all of the Advanced EoB data contained within an Advance EoB Bundle.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 | |
serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
Slices for identifier | 0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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 | |||
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 pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
total:submitted | S | 1..1 | BackboneElement | Total provider submitted amount |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
total:memberliability | S | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
total:innetwork | S | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
total:outofnetwork | S | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
total:noncovered | S | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
total:negotiated | S | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
total:eligible | S | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
total:benefit | S | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
payment | 0..0 | |||
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization. | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
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 |
Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS from this IG |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | 0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
Slices for identifier | 0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |
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 |
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. 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 |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
dataAbsentReason | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason" | |
value[x] | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable | |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information |
Slices for total | Σ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) |
amount | Σ | 1..1 | Money | Financial total for the category |
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |
amount | Σ | 1..1 | Money | Financial total for the category |
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |
amount | Σ | 1..1 | Money | Financial total for the category |
processNote | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization. | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
benefitPeriod | 1..1 | Period | When the benefits are applicable | |
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |
financial | 1..* | BackboneElement | Benefit Summary | |
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 |
Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier:INTER.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:INTER.type | extensible | Pattern: INTER("Intermediary System Identifier")http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | extensible | Pattern: estimate-summaryhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x] | required | Pattern: not-applicablehttp://hl7.org/fhir/ValueSet/data-absent-reason from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.total.category | extensible | PCTTotalhttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG | |
ExplanationOfBenefit.total:submitted.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:memberliability.category | example | Pattern: memberliabilityhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:innetwork.category | example | Pattern: innetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:outofnetwork.category | example | Pattern: outofnetworkhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:noncovered.category | example | Pattern: noncoveredhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:negotiated.category | example | Pattern: negotiatedhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:eligible.category | example | Pattern: eligiblehttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.total:benefit.category | example | Pattern: benefithttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.category | required | PCTBenefitBalanceCategoryVShttp://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG | |
ExplanationOfBenefit.benefitBalance.unit | required | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.term | required | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | |
ExplanationOfBenefit.benefitBalance.financial.type | required | PCTFinancialTypeVS (a valid code from PCT Financial Type Code System)http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS from this IG |
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.
| |||||
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 | |||||
serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription | ||||
outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | 0..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |||||
identifier:INTER | 0..* | Identifier | Intermediary System Identifier | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: INTER | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Intermediary System Identifier | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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 | |||||
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 pattern:category | ||||
total:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:submitted | SΣ | 1..1 | BackboneElement | Total provider submitted amount | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:memberliability | SΣ | 0..1 | BackboneElement | Total member liability - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:innetwork | SΣ | 0..1 | BackboneElement | Total in network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: innetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:outofnetwork | SΣ | 0..1 | BackboneElement | Total out of network amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: outofnetwork | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:noncovered | SΣ | 0..1 | BackboneElement | Total noncovered amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: noncovered | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:negotiated | SΣ | 0..1 | BackboneElement | Total negotiated amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: negotiated | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:eligible | SΣ | 0..1 | BackboneElement | Total eligible amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
total:benefit | SΣ | 0..1 | BackboneElement | Total benefit amount - Must include in non-zero total across all AEoBs | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
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. This may include a note about out of network providers or prior authorization. | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
processNoteClass | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 1..1 | Period | When the benefits are applicable | |||||
benefitBalance | 1..* | BackboneElement | Balance by Benefit Category | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required) | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required) | |||||
term | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required) | |||||
financial | 1..* | BackboneElement | Benefit Summary | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||