Notes on Fields

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

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.

Changes since version 1.1.0:

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ExplanationOfBenefit	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
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
extension: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
extension:serviceDescription	SC	0..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier		1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by value:type
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
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/v2-0203
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: UCID
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
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 (required)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient	Σ	1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services
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
extension: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)
coding	ΣC	0..*	Coding	Code defined by a terminology system Constraints: pct-cpt-display
modifier	S	0..4	CodeableConcept	Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
coding	ΣC	0..*	Coding	Code defined by a terminology system Constraints: pct-cpt-display
serviced[x]		1..1		This is the planned or estimated date(s)s of service
servicedDate			date
servicedPeriod			Period
quantity	S	0..1	SimpleQuantity(4.0.1)	Count of products or services
Slices for adjudication	S	1..*	BackboneElement	Adjudication details Slice: Unordered, Open by value: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
extension:subjectToMedicalMgmt		1..1	CodeableConcept	Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
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) 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: medicalmanagement
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: adjustmentreason
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
Slices for adjudication	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Open by value: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
extension:subjectToMedicalMgmt		1..1	CodeableConcept	Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
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) 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: medicalmanagement
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: adjustmentreason
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
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
Slices for total	Σ	3..*	BackboneElement	Adjudication totals Slice: Unordered, Open by value:category
total:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible)
amount	Σ	1..1	Money	Financial total for the category
total:submitted	SΣ	1..1	BackboneElement	Total provider submitted amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:memberliability	SΣ	1..1	BackboneElement	Total member liability
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: memberliability
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:eligible	SΣ	1..1	BackboneElement	Total eligible amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: eligible
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:innetwork	SΣ	0..1	BackboneElement	Total in network amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: innetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:outofnetwork	SΣ	0..1	BackboneElement	Total out of network amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: outofnetwork
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:noncovered	SΣ	0..1	BackboneElement	Total noncovered amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: noncovered
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:negotiated	SΣ	0..1	BackboneElement	Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: negotiated
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
total:benefit	SΣ	0..1	BackboneElement	Total benefit amount - only include when total type is applicable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefit
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
amount	Σ	1..1	Money	Financial total for the category
processNote		1..*	BackboneElement	Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:processNoteClass		0..1	CodeableConcept	ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
benefitPeriod		1..1	Period	When the benefits are applicable
benefitBalance		1..*	BackboneElement	Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: PCT benefitBalance.category codes (required)
text	SΣ	1..1	string	Plain text representation of the concept
unit		1..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (required)
term		1..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (required)
financial		1..*	BackboneElement	Benefit Summary
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:remaining	S	0..1	unsignedInt S, Money S	Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: PCT Financial Type Value Set (required)
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.identifier:uniqueclaimid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.type	extensible	Pattern Value: UCID http://hl7.org/fhir/ValueSet/identifier-type|4.0.1 From the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 From the FHIR Standard
ExplanationOfBenefit.type	required	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard
ExplanationOfBenefit.use	required	Pattern Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority From the FHIR Standard
ExplanationOfBenefit.claim.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ExplanationOfBenefit.item.revenue	required	PCTGFEItemRevenueVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS From this IG
ExplanationOfBenefit.item.productOrService	required	USClaimMedicalProductOrServiceCodes http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes From this IG
ExplanationOfBenefit.item.modifier	required	PCTGFEItemCptHcpcsVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS From this IG
ExplanationOfBenefit.item.adjudication.category	extensible	PCTAdjudicationCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:medicalmanagement.category	extensible	Pattern Value: medicalmanagement http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category	extensible	Pattern Value: benefitpaymentstatus http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason	required	PCTPayerBenefitPaymentStatusVS(a valid code from PCT Network Status) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS From this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.category	extensible	Pattern Value: adjustmentreason http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS From this IG
ExplanationOfBenefit.item.adjudication:submitted.category	extensible	Pattern Value: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:memberliability.category	extensible	Pattern Value: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:eligible.category	extensible	Pattern Value: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.item.adjudication:benefit.category	extensible	Pattern Value: benefit http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication.category	extensible	PCTAdjudicationCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:medicalmanagement.category	extensible	Pattern Value: medicalmanagement http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.category	extensible	Pattern Value: billingnetworkstatus http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason	required	PCTPayerBenefitPaymentStatusVS(a valid code from PCT Network Status) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS From this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category	extensible	Pattern Value: renderingnetworkstatus http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason	required	PCTPayerBenefitPaymentStatusVS(a valid code from PCT Network Status) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS From this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category	extensible	Pattern Value: benefitpaymentstatus http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason	required	PCTPayerBenefitPaymentStatusVS(a valid code from PCT Network Status) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS From this IG
ExplanationOfBenefit.adjudication:adjustmentreason.category	extensible	Pattern Value: adjustmentreason http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:adjustmentreason.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS From this IG
ExplanationOfBenefit.adjudication:submitted.category	extensible	Pattern Value: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:memberliability.category	extensible	Pattern Value: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:eligible.category	extensible	Pattern Value: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.adjudication:benefit.category	extensible	Pattern Value: benefit http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS From this IG
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:submitted.category	extensible	Pattern Value: submitted http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:memberliability.category	extensible	Pattern Value: memberliability http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:eligible.category	extensible	Pattern Value: eligible http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:innetwork.category	extensible	Pattern Value: innetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:outofnetwork.category	extensible	Pattern Value: outofnetwork http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:noncovered.category	extensible	Pattern Value: noncovered http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:negotiated.category	extensible	Pattern Value: negotiated http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.total:benefit.category	extensible	Pattern Value: benefit http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal From this IG
ExplanationOfBenefit.benefitBalance.category	required	PCTBenefitBalanceCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS From this IG
ExplanationOfBenefit.benefitBalance.unit	required	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit From the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	required	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term From the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.type	required	PCTFinancialTypeVS(a valid code from PCT Financial Type Code System) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ExplanationOfBenefit	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ExplanationOfBenefit	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ExplanationOfBenefit	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ExplanationOfBenefit	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ExplanationOfBenefit	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
pct-aeob-1	error	ExplanationOfBenefit	Advanced 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-2	error	ExplanationOfBenefit	Advanced 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-3	error	ExplanationOfBenefit	Advanced 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()
pct-cpt-display	error	ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding	CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) : system = 'http://www.ama-assn.org/go/cpt' implies display.exists()