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.

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

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
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
outOfNetworkProviderInfo	S	0..1	url	In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
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
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ExplanationOfBenefit.type	required	PCTAEOBTypeVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority 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: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.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG
ExplanationOfBenefit.adjudication.category	extensible	PCTAdjudicationCategoryVS 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.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.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.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.benefitBalance.category	required	PCTBenefitBalanceCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS from this IG
ExplanationOfBenefit.benefitBalance.unit	required	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	required	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.type	required	PCTFinancialTypeVS (a valid code from PCT Financial Type Code System) http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
pct-aeob-1	error	ExplanationOfBenefit	Institutional 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	Institutional 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	Institutional 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()

Name	Flags	Card.	Type	Description & Constraints
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
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
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.identifier:INTER.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.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: uc("Unique Claim ID") http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	required	PCTAEOBTypeVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS from this IG
ExplanationOfBenefit.use	required	Pattern: 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	example	Pattern: medicalmanagement http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category	example	Pattern: benefitpaymentstatus http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
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	example	Pattern: adjustmentreason http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG
ExplanationOfBenefit.item.adjudication:submitted.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:memberliability.category	example	Pattern: memberliability http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:eligible.category	example	Pattern: eligible http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefit.category	example	Pattern: benefit http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication.category	extensible	PCTAdjudicationCategoryVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS from this IG
ExplanationOfBenefit.adjudication:medicalmanagement.category	example	Pattern: medicalmanagement http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.category	example	Pattern: billingnetworkstatus http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
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	example	Pattern: renderingnetworkstatus http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
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	example	Pattern: benefitpaymentstatus http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
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	example	Pattern: adjustmentreason http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reason	required	PCTAdjustmentReasonVS http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS from this IG
ExplanationOfBenefit.adjudication:submitted.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication:memberliability.category	example	Pattern: memberliability http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication:eligible.category	example	Pattern: eligible http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication:benefit.category	example	Pattern: benefit http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total.category	extensible	PCTTotal http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal from this IG
ExplanationOfBenefit.total:submitted.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:memberliability.category	example	Pattern: memberliability http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:innetwork.category	example	Pattern: innetwork http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:outofnetwork.category	example	Pattern: outofnetwork http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:noncovered.category	example	Pattern: noncovered http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:negotiated.category	example	Pattern: negotiated http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:eligible.category	example	Pattern: eligible http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.total:benefit.category	example	Pattern: benefit http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
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
pct-aeob-1	error	ExplanationOfBenefit	Institutional 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	Institutional 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	Institutional 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()