Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

## Resource Profile: PCT Advanced EOB Summary

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary | Version: 2.0.1
Standards status: Trial-use | Maturity Level: 1 | Computable Name: PCTAdvancedEOBSummary
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.5

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

#### 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.

Usages:

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

You can also check for usages in the FHIR IG Statistics

Changes since version 1.1.0:

- New Content

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Explanation of Benefit resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created | Σ | 1..1 | dateTime | The date and time this summary was generated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
Slices for total | Σ | 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 | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:submitted.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:memberliability.​category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:eligible.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:innetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:outofnetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:noncovered.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:negotiated.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:benefit.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  |  | ExplanationOfBenefit |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
type |  | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
subType |  | 0..0 |  | More granular claim type
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination
patient |  | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod |  | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created |  | 1..1 | dateTime | The date and time this summary was generated.
enterer |  | 0..0 |  | Author of the claim
insurer |  | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider |  |  |  |
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Required Pattern: not-applicable
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..0 |  | Logical reference, when literal reference is not known
display |  | 0..0 |  | Text alternative for the resource
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..0 |  | For whom to reserve funds
fundsReserve |  | 0..0 |  | Funds reserved status
prescription |  | 0..0 |  | Prescription authorizing services or products
originalPrescription |  | 0..0 |  | Original prescription if superceded by fulfiller
payee |  | 0..0 |  | Recipient of benefits payable
referral |  | 0..0 |  | Treatment Referral
facility |  | 0..0 |  | Servicing Facility
claim |  | 0..0 |  | Claim reference
preAuthRef |  | 0..0 |  | Preauthorization reference
preAuthRefPeriod |  | 0..0 |  | Preauthorization in-effect period
supportingInfo |  | 0..0 |  | Supporting information
precedence |  | 0..0 |  | Precedence (primary, secondary, etc.)
insurance |  |  |  |
coverage |  | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 0..0 |  | Product or service provided
addItem |  | 0..0 |  | Insurer added line items
adjudication |  | 0..0 |  | Header-level adjudication
Slices for total |  | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible)
total:submitted | S | 1..1 | BackboneElement | Total provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
total:memberliability | S | 1..1 | BackboneElement | Total 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
total:eligible | S | 1..1 | BackboneElement | Total 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
total:innetwork | S | 0..1 | BackboneElement | Total in network amount - only include when total type is applicable
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 - only include when total type is applicable
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 - only include when total type is applicable
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 - 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
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:benefit | S | 0..1 | BackboneElement | Total benefit amount - only include when total type is applicable
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
payment |  | 0..0 |  | Payment Details
processNote |  | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:processNoteClass |  | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
benefitPeriod |  | 1..1 | Period | When the benefits are applicable
benefitBalance |  | 1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
category |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required)
text | S | 1..1 | string | Plain text representation of the concept
unit |  | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required)
term |  | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required)
financial |  | 1..* | BackboneElement | Benefit Summary
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
type |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Open by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Explanation of Benefit resource
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for the resource
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created | Σ | 1..1 | dateTime | The date and time this summary was generated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
related |  | 0..* | BackboneElement | Prior or corollary claims
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference |  | 0..1 | Identifier | File or case reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider |  | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role |  | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] |  | 1..1 |  | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
insurance | Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
preAuthRef |  | 0..* | string | Prior authorization reference number
accident |  | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date |  | 0..1 | date | When the incident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Where the event occurred
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
Slices for total | Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total provider submitted amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total member liability
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total eligible amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total in network amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total out of network amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total noncovered amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total benefit amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
amount | Σ | 1..1 | Money | Financial total for the category
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:processNoteClass |  | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 1..1 | Period | When the benefits are applicable
benefitBalance |  | 1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | S Σ | 1..1 | string | Plain text representation of the concept
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required)
term |  | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required)
financial |  | 1..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​accident.type | Base | extensible | ActIncidentCode | 📍3.0.0 | THO v6.5
ExplanationOfBenefit.​item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:submitted.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:memberliability.​category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:eligible.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:innetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:outofnetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:noncovered.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:negotiated.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:benefit.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 17 elements
Must-Support: 13 elements
Prohibited: 22 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)
- PCT Coverage (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit

Slices

This structure defines the following Slices:

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

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Explanation of Benefit resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created | Σ | 1..1 | dateTime | The date and time this summary was generated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
Slices for total | Σ | 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 | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 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)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:submitted.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:memberliability.​category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:eligible.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:innetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:outofnetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:noncovered.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:negotiated.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:benefit.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

Differential View

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  |  | ExplanationOfBenefit |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
type |  | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
subType |  | 0..0 |  | More granular claim type
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: predetermination
patient |  | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod |  | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created |  | 1..1 | dateTime | The date and time this summary was generated.
enterer |  | 0..0 |  | Author of the claim
insurer |  | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider |  |  |  |
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Required Pattern: not-applicable
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..0 |  | Logical reference, when literal reference is not known
display |  | 0..0 |  | Text alternative for the resource
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..0 |  | For whom to reserve funds
fundsReserve |  | 0..0 |  | Funds reserved status
prescription |  | 0..0 |  | Prescription authorizing services or products
originalPrescription |  | 0..0 |  | Original prescription if superceded by fulfiller
payee |  | 0..0 |  | Recipient of benefits payable
referral |  | 0..0 |  | Treatment Referral
facility |  | 0..0 |  | Servicing Facility
claim |  | 0..0 |  | Claim reference
preAuthRef |  | 0..0 |  | Preauthorization reference
preAuthRefPeriod |  | 0..0 |  | Preauthorization in-effect period
supportingInfo |  | 0..0 |  | Supporting information
precedence |  | 0..0 |  | Precedence (primary, secondary, etc.)
insurance |  |  |  |
coverage |  | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 0..0 |  | Product or service provided
addItem |  | 0..0 |  | Insurer added line items
adjudication |  | 0..0 |  | Header-level adjudication
Slices for total |  | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible)
total:submitted | S | 1..1 | BackboneElement | Total provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
total:memberliability | S | 1..1 | BackboneElement | Total 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
total:eligible | S | 1..1 | BackboneElement | Total 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
total:innetwork | S | 0..1 | BackboneElement | Total in network amount - only include when total type is applicable
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 - only include when total type is applicable
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 - only include when total type is applicable
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 - 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
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:benefit | S | 0..1 | BackboneElement | Total benefit amount - only include when total type is applicable
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
payment |  | 0..0 |  | Payment Details
processNote |  | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:processNoteClass |  | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
benefitPeriod |  | 1..1 | Period | When the benefits are applicable
benefitBalance |  | 1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
category |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required)
text | S | 1..1 | string | Plain text representation of the concept
unit |  | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required)
term |  | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required)
financial |  | 1..* | BackboneElement | Benefit Summary
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
type |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Open by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Open by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit |  | 0..* | ExplanationOfBenefit | Explanation of Benefit resource
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for the resource
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: estimate-summary
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 1..1 | Period | The full Period of Care for all services or products included in the estimate from the first event to the last event.
created | Σ | 1..1 | dateTime | The date and time this summary was generated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Required Pattern: not-applicable
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
related |  | 0..* | BackboneElement | Prior or corollary claims
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference |  | 0..1 | Identifier | File or case reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider |  | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role |  | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] |  | 1..1 |  | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
insurance | Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
preAuthRef |  | 0..* | string | Prior authorization reference number
accident |  | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date |  | 0..1 | date | When the incident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Where the event occurred
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
Slices for total | Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total provider submitted amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total member liability
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 1..1 | BackboneElement | Total eligible amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total in network amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total out of network amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total noncovered amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 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
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 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 | S Σ | 0..1 | BackboneElement | Total benefit amount - only include when total type is applicable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT Total Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
amount | Σ | 1..1 | Money | Financial total for the category
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 1..* | BackboneElement | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:processNoteClass |  | 0..1 | CodeableConcept | ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 1..1 | Period | When the benefits are applicable
benefitBalance |  | 1..* | BackboneElement | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT benefitBalance.category codes (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | S Σ | 1..1 | string | Plain text representation of the concept
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 1..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (required)
term |  | 1..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (required)
financial |  | 1..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:remaining | S | 0..1 | unsignedInt S, Money S | Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: PCT Financial Type Value Set (required)
Slices for allowed[x] |  | 1..1 | Money | Benefits allowed Slice: Unordered, Closed by type:$this
allowed[x]:allowedMoney |  | 1..1 | Money | Benefits allowed
Slices for used[x] |  | 1..1 | Money | Benefits used Slice: Unordered, Closed by type:$this
used[x]:usedMoney |  | 1..1 | Money | Benefits used
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​accident.type | Base | extensible | ActIncidentCode | 📍3.0.0 | THO v6.5
ExplanationOfBenefit.​item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​total.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:submitted.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:memberliability.​category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:eligible.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:innetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:outofnetwork.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:noncovered.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:negotiated.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​total:benefit.category | Base | extensible | PCT Total Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.category | Base | required | PCT benefitBalance.category codes | 📦2.0.1 | This IG
ExplanationOfBenefit.​benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit | Base | required | Unit Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | required | Benefit Term Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | required | PCT Financial Type Value Set | 📦2.0.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 17 elements
Must-Support: 13 elements
Prohibited: 22 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)
- PCT Coverage (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit

Slices

This structure defines the following Slices:

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

Maturity: 1

Other representations of profile: CSV, Excel, Schematron