Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

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

Resource Profile: PCT Advanced EOB

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob Version: 2.0.0-ballot
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTAdvancedEOB
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.6

The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.

Notes on Fields

  • .created: .created values convey the date and time the estimate was calculated, based on what was known about the state of the member’s benefits and accumulators for a given benefit period/plan year at that point in time (the .created date and time).
  • .benefitPeriod: .benefitPeriod values convey the term of benefits (a.k.a. "plan year") that the benefits used to calculate the estimate were based on.
    • If included, the estimate was based on the member’s benefits and accumulators for the benefit period/plan year explicitly conveyed in .benefitPeriod, as of the .created date and time.
    • If not included, it is understood that the estimate was based on the member’s benefits and accumulators for the current benefit period/plan year, as of the .created date and time.
  • .total.amount: Eligible amount = submitted amount - the noncovered amount - discount. The subscriber pays the member liability = deductible + coinsurance + copay + noncovered (if applicable). The eligible amount - the member liability is the potential payer's payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • Working together .created values and .benefitPeriod values explicitly convey the temporal context for the state of benefits and accumulators that were used to calculate the estimate communicated in an advanced EOB. The state of a member’s benefits and accumulators for a given benefit period or the benefit period in effect may change between the date that an estimate is generated (.created) and when the services being estimated are actually rendered (e.g., the actual date of service), resulting in a difference between the estimated vs. actual cost to the member.
  • Examples

    Example 1 – Estimation based on current benefit period
    • Situation:
      • A group health plan produces an advance cost estimate on July 2, 2023, for services scheduled on August 23, 2023.
      • The plan uses the state of the member’s current 2023 benefit period/plan year benefits and accumulators when calculating the estimate.
      • The plan’s deductible for the 2023 benefit period benefits is $1500.
      • At the time, the group health plan produces the estimate on July 2, 2023, the member has paid $1000 in eligible health care expenses against their $1500/2023 plan year deductible.
    • Result:
      • The estimate is produced on July 2, 2023 (.created = “2023-07-02T13:28:17-05:00”).
      • The benefit period used as the basis for the estimation is the current 2023 benefit period/plan year (.benefitPeriod.start = “2023-01-01” & .benefitPeriod.end = “2023-12-31”).
      • The estimated cost to the member is based on the fact that as of July 2, 2023 13:28:17-05:00, they have only met $1000 of their $1500/2023 plan year deductible.
    Example 2 – Estimation based on a future benefit period
    • Situation:
      • The payer can support estimations based on a future benefit period.
      • A group health plan is producing an advance cost estimate on December 15, 2024, for services scheduled in 2025.
      • The plan uses the 2025 term of benefits (a.k.a. "plan year") when calculating the estimate.
      • The plan’s deductible for the 2025 term of benefits is $1500.
      • At the time, the group health plan produces the estimate on December 15, 2024, the member has incurred no claims against the 2025 term of benefits, and they have paid $0 in eligible health care expenses against their $1500/2025 plan year deductible.
    • Result:
      • The estimate is produced on December 15, 2024 (.created = "2024-12-15T12:10:05-05:00").
      • The benefit period used as the basis for the estimation is the 2025 plan year (.benefitPeriod.start = "2025-01-01" & .benefitPeriod.end = "2025-12-31").
      • The estimated cost to the member is based on the fact that as of December 15, 2024 12:10:05-05:00, they have not met any portion of their $1500/2025 plan year deductible.

Usage:

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* ExplanationOfBenefit Explanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
... gfeReference 1..* Reference(PCT GFE Bundle) The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
... serviceDescription SC 0..1 string Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..* Identifier Intermediary System Identifier
..... type 1..1 CodeableConcept Description of identifier
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: INTER
....... display 1..1 string Representation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1 Identifier Unique Claim ID
..... type 1..1 CodeableConcept Description of identifier
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 1..1 string Representation defined by the system
Fixed Value: Unique Claim ID
... type 1..1 CodeableConcept Category or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use 1..1 code claim | preauthorization | predetermination
Required Pattern: predetermination
... patient 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
... created 1..1 dateTime The date and time this estimate was calculated.
... insurer 1..1 Reference(PCT Organization) Party responsible for reimbursement
... provider 1..1 Reference(PCT Practitioner | PCT Organization) Party responsible for the claim
... priority S 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1 Reference(Claim) Claim reference
.... identifier 1..1 Identifier GFE identifier of the originally submitted claim
..... system S 0..1 uri The namespace for the identifier value
..... value 1..1 string The value that is unique
... insurance
.... coverage 1..1 Reference(PCT Coverage) Insurance information
... item 1..* BackboneElement Product or service provided
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... serviceDescription SC 0..1 string Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S 0..4 CodeableConcept Product or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1 date, Period This is the planned or estimated date(s)s of service
.... quantity S 0..1 SimpleQuantity Count of products or services
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1 CodeableConcept Type of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S 0..* BackboneElement Adjudication details
...... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalmanagement
...... amount 0..0
...... value 0..0
..... adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S 0..1 BackboneElement Provider submitted amount
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S 0..1 BackboneElement Member liability
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S 0..1 BackboneElement Eligible amount
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S 0..1 BackboneElement Benefit amount
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category 1..1 CodeableConcept Type of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S 0..* BackboneElement Header-level adjudication
..... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalmanagement
..... amount 0..0
..... value 0..0
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing Provider Network Status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering Provider Network Status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S 0..1 BackboneElement Provider submitted amount
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S 0..1 BackboneElement Member liability
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S 0..1 BackboneElement Eligible amount
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S 0..1 BackboneElement Benefit amount
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
... Slices for total 1..* BackboneElement Adjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: PCT Total Value Set (extensible)
.... total:submitted S 1..1 BackboneElement Total provider submitted amount
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
.... total:memberliability S 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
.... total:innetwork S 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: innetwork
.... total:outofnetwork S 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: outofnetwork
.... total:noncovered S 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: noncovered
.... total:negotiated S 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: negotiated
.... total:eligible S 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
.... total:benefit S 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1 CodeableConcept ProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
... benefitPeriod 1..1 Period When the benefits are applicable
... benefitBalance 1..* BackboneElement Balance by Benefit Category
.... category 1..1 CodeableConcept Benefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (required)
.... term 1..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..* BackboneElement Benefit Summary
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... remaining S 0..1 unsignedInt S, Money S Benefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... type 1..1 CodeableConcept Benefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S 1..1 Benefits allowed
...... allowedUnsignedInt unsignedInt S
...... allowedMoney Money S
..... used[x] S 1..1 Benefits used
...... usedUnsignedInt unsignedInt S
...... usedMoney Money S

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS
from this IG
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS
from this IG
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS
from this IG
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS
from this IG
ExplanationOfBenefit.total.categoryextensiblePCTTotal
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
from this IG
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
from this IG
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
: extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()
pct-aeob-2errorExplanationOfBenefitInstitutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
: adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()
pct-aeob-3errorExplanationOfBenefitInstitutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
: adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* ExplanationOfBenefit Explanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
... gfeReference 1..* Reference(PCT GFE Bundle) The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..* Identifier Intermediary System Identifier
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: INTER
....... display 1..1 string Representation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1 Identifier Unique Claim ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 1..1 string Representation defined by the system
Fixed Value: Unique Claim ID
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ 1..1 CodeableConcept Category or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: predetermination
... patient Σ 1..1 Reference(HRex Patient Demographics) The recipient of the products and services
... created Σ 1..1 dateTime The date and time this estimate was calculated.
... insurer Σ 1..1 Reference(PCT Organization) Party responsible for reimbursement
... provider Σ 1..1 Reference(PCT Practitioner | PCT Organization) Party responsible for the claim
... priority S 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1 Reference(Claim) Claim reference
.... identifier Σ 1..1 Identifier GFE identifier of the originally submitted claim
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... system SΣ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 1..1 string The value that is unique
Example General: 123456
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... insurance Σ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(PCT Coverage) Insurance information
... item 1..* BackboneElement Product or service provided
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... serviceDescription SC 0..1 string Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S 0..4 CodeableConcept Product or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1 This is the planned or estimated date(s)s of service
..... servicedDate date
..... servicedPeriod Period
.... quantity S 0..1 SimpleQuantity Count of products or services
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S 0..* BackboneElement Adjudication details
...... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalmanagement
..... adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S 0..1 BackboneElement Provider submitted amount
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S 0..1 BackboneElement Member liability
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S 0..1 BackboneElement Eligible amount
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S 0..1 BackboneElement Benefit amount
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S 0..* BackboneElement Header-level adjudication
..... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalmanagement
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing Provider Network Status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering Provider Network Status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S 0..1 BackboneElement Provider submitted amount
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S 0..1 BackboneElement Member liability
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S 0..1 BackboneElement Eligible amount
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S 0..1 BackboneElement Benefit amount
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
... Slices for total Σ 1..* BackboneElement Adjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: PCT Total Value Set (extensible)
..... amount Σ 1..1 Money Financial total for the category
.... total:submitted SΣ 1..1 BackboneElement Total provider submitted amount
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... amount Σ 1..1 Money Financial total for the category
.... total:memberliability SΣ 0..1 BackboneElement Total member liability - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: memberliability
..... amount Σ 1..1 Money Financial total for the category
.... total:innetwork SΣ 0..1 BackboneElement Total in network amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: innetwork
..... amount Σ 1..1 Money Financial total for the category
.... total:outofnetwork SΣ 0..1 BackboneElement Total out of network amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: outofnetwork
..... amount Σ 1..1 Money Financial total for the category
.... total:noncovered SΣ 0..1 BackboneElement Total noncovered amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: noncovered
..... amount Σ 1..1 Money Financial total for the category
.... total:negotiated SΣ 0..1 BackboneElement Total negotiated amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: negotiated
..... amount Σ 1..1 Money Financial total for the category
.... total:eligible SΣ 0..1 BackboneElement Total eligible amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: eligible
..... amount Σ 1..1 Money Financial total for the category
.... total:benefit SΣ 0..1 BackboneElement Total benefit amount - Must include in non-zero total across all AEoBs
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefit
..... amount Σ 1..1 Money Financial total for the category
... processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1 CodeableConcept ProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... benefitPeriod 1..1 Period When the benefits are applicable
... benefitBalance 1..* BackboneElement Balance by Benefit Category
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (required)
.... term 1..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..* BackboneElement Benefit Summary
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... remaining S 0..1 unsignedInt, Money Benefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S 1..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedMoney Money
..... used[x] S 1..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc("Unique Claim ID")
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS
from this IG
ExplanationOfBenefit.userequiredPattern: predetermination
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.claim.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS
from this IG
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS
from this IG
ExplanationOfBenefit.item.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS
from this IG
ExplanationOfBenefit.item.adjudication:submitted.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:memberliability.categoryexamplePattern: memberliability
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:eligible.categoryexamplePattern: eligible
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefit.categoryexamplePattern: benefit
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS
from this IG
ExplanationOfBenefit.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS (a valid code from PCT Network Status)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS
from this IG
ExplanationOfBenefit.adjudication:submitted.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:memberliability.categoryexamplePattern: memberliability
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:eligible.categoryexamplePattern: eligible
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefit.categoryexamplePattern: benefit
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total.categoryextensiblePCTTotal
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal
from this IG
ExplanationOfBenefit.total:submitted.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:memberliability.categoryexamplePattern: memberliability
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:innetwork.categoryexamplePattern: innetwork
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:outofnetwork.categoryexamplePattern: outofnetwork
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:noncovered.categoryexamplePattern: noncovered
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:negotiated.categoryexamplePattern: negotiated
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:eligible.categoryexamplePattern: eligible
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.total:benefit.categoryexamplePattern: benefit
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS
from this IG
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)
http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
: extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()
pct-aeob-2errorExplanationOfBenefitInstitutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
: adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()
pct-aeob-3errorExplanationOfBenefitInstitutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
: adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* ExplanationOfBenefit Explanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
... gfeReference 1..* Reference(PCT GFE Bundle) The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
... serviceDescription SC 0..1 string Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..* Identifier Intermediary System Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .