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

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob | Version: 2.0.1
Standards status: Trial-use | Maturity Level: 2 | Computable Name: PCTAdvancedEOB
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.6

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

#### Notes on Fields

- .created: .created values convey the date and time the estimate was calculated, based on what was known about the state of the member’s benefits and accumulators for a given benefit period/plan year at that point in time (the .created date and time).
- The gfeReference Extension is used to point to the GFE Bundle for which the originating GFE is contained. This along with the .claim.identifier can be used to identify the originating GFE this AEOB addresses. Note that it is common for there to be a one-to-one relationship between an AEOB and a GFE, however, this is not always the case.
- .benefitPeriod: .benefitPeriod values convey the term of benefits (a.k.a. "plan year") that the benefits used to calculate the estimate were based on.

- If included, the estimate was based on the member’s benefits and accumulators for the benefit period/plan year explicitly conveyed in .benefitPeriod, as of the .created date and time.
- If not included, it is understood that the estimate was based on the member’s benefits and accumulators for the current benefit period/plan year, as of the .created date and time.

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

#### Examples

##### Example 1 – Estimation based on current benefit period

- Situation:
  - A group health plan produces an advance cost estimate on July 2, 2023, for services scheduled on August 23, 2023.
  - The plan uses the state of the member’s current 2023 benefit period/plan year benefits and accumulators when calculating the estimate.
  - The plan’s deductible for the 2023 benefit period benefits is $1500.
  - At the time, the group health plan produces the estimate on July 2, 2023, the member has paid $1000 in eligible health care expenses against their $1500/2023 plan year deductible.
- Result:
  - The estimate is produced on July 2, 2023 (.created = “2023-07-02T13:28:17-05:00”).
  - The benefit period used as the basis for the estimation is the current 2023 benefit period/plan year (.benefitPeriod.start = “2023-01-01” & .benefitPeriod.end = “2023-12-31”).
  - The estimated cost to the member is based on the fact that as of July 2, 2023 13:28:17-05:00, they have only met $1000 of their $1500/2023 plan year deductible.

##### Example 2 – Estimation based on a future benefit period

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

Usages:

- Use this Profile: PCT AEOB Packet
- Refer to this Profile: PCT AEOB Composition
- Examples for this Profile: ExplanationOfBenefit/PCT-AEOB-1
- CapabilityStatements using this Profile: Patient Cost Transparency Implementation Guide Payer Capability Statement

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 | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
claim |  | 1..1 | Reference(Claim) | Claim reference
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | S Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 1..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
coding | Σ C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
coding | Σ C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
serviced[x] |  | 1..1 |  | This is the planned or estimated date(s)s of service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for total | Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | 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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​identifier:uniqueclaimid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.revenue | Base | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
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()`
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 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
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
type |  | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
type |  | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
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
created |  | 1..1 | dateTime | The date and time this estimate was calculated.
insurer |  | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider |  | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
claim |  | 1..1 | Reference(Claim) | Claim reference
identifier |  | 1..1 | Identifier | GFE identifier of the originally submitted claim
system | S | 0..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
insurance |  |  |  |
coverage |  | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 1..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
coding | C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
coding | C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
serviced[x] |  | 1..1 | date, Period | This is the planned or estimated date(s)s of service
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
amount |  | 0..0 |  | Monetary amount
value |  | 0..0 |  | Non-monitary value
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
amount |  | 0..0 |  | Monetary amount
value |  | 0..0 |  | Non-monitary value
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
Slices for total |  | 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
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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.revenue | Base | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
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

#### Constraints

Id | Grade | Path(s) | Description | Expression
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
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 |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
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 | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated.
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
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
prescription |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
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
type |  | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment Referral
facility |  | 0..1 | Reference(Location) | Servicing Facility
claim |  | 1..1 | Reference(Claim) | Claim reference
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | S Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
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
preAuthRef |  | 0..* | string | Preauthorization reference
preAuthRefPeriod |  | 0..* | Period | Preauthorization in-effect period
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.
supportingInfo |  | 0..* | BackboneElement | Supporting 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 | Information instance identifier
category |  | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
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
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
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) |
item |  | 1..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
careTeamSequence |  | 0..* | positiveInt | Applicable care team members
diagnosisSequence |  | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (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 C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
text | Σ | 0..1 | string | Plain text representation of the concept
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (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 C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
text | Σ | 0..1 | string | Plain text representation of the concept
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 1..1 |  | This is the planned or estimated date(s)s of service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication: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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:submitted | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:memberliability | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:eligible | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefit | S | 0..1 | BackboneElement | Benefit 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
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 | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
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 | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
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
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
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
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
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
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication: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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:submitted | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:memberliability | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:eligible | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefit | S | 0..1 | BackboneElement | Benefit 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
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
payment |  | 0..1 | BackboneElement | Payment Details
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
type |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserve | Base | example | FundsReserve | 📍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.​claim.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.type | Base | extensible | IdentifierType | 📍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 | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
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 | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:memberliability.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:eligible.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefit.​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.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:medicalmanagement.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:memberliability.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:eligible.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefit.​reason | Base | example | Adjudication Reason 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()`
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 23 elements(4 nested mandatory elements)
Must-Support: 38 elements
Prohibited: 4 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 Practitioner (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner)
- 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/gfeReference
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
- 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.identifier
- The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
- The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication
- The element 1 is sliced based on the value of ExplanationOfBenefit.total

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: predetermination
patient | Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated.
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
claim |  | 1..1 | Reference(Claim) | Claim reference
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | S Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 1..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
coding | Σ C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
coding | Σ C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
serviced[x] |  | 1..1 |  | This is the planned or estimated date(s)s of service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for total | Σ | 3..* | BackboneElement | Adjudication totals Slice: Unordered, Open by value:category
total:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | 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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​identifier:uniqueclaimid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.revenue | Base | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
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()`
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

Differential View

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 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
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
type |  | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
type |  | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
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
created |  | 1..1 | dateTime | The date and time this estimate was calculated.
insurer |  | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider |  | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
claim |  | 1..1 | Reference(Claim) | Claim reference
identifier |  | 1..1 | Identifier | GFE identifier of the originally submitted claim
system | S | 0..1 | uri | The namespace for the identifier value
value |  | 1..1 | string | The value that is unique
insurance |  |  |  |
coverage |  | 1..1 | Reference(PCT Coverage) | Insurance information
item |  | 1..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
coding | C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
coding | C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
serviced[x] |  | 1..1 | date, Period | This is the planned or estimated date(s)s of service
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
amount |  | 0..0 |  | Monetary amount
value |  | 0..0 |  | Non-monitary value
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
amount |  | 0..0 |  | Monetary amount
value |  | 0..0 |  | Non-monitary value
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
adjudication:submitted | S | 0..1 | BackboneElement | Provider submitted amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
adjudication:memberliability | S | 0..1 | BackboneElement | Member liability
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
adjudication:eligible | S | 0..1 | BackboneElement | Eligible amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
adjudication:benefit | S | 0..1 | BackboneElement | Benefit amount
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
Slices for total |  | 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
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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.revenue | Base | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
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

#### Constraints

Id | Grade | Path(s) | Description | Expression
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3
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 |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:gfeReference |  | 1..* | Reference(PCT GFE Bundle) | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
extension:outOfNetworkProviderInfo | S | 0..1 | url | In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier |  | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type
identifier:uniqueclaimid |  | 1..1 | Identifier | Unique Claim ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: UCID
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required)
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
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 | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | The date and time this estimate was calculated.
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 1..1 | Reference(PCT Organization) | Party responsible for reimbursement
provider | Σ | 1..1 | Reference(PCT Practitioner | PCT Organization) | Party responsible for the claim
priority | S | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
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
prescription |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
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
type |  | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment Referral
facility |  | 0..1 | Reference(Location) | Servicing Facility
claim |  | 1..1 | Reference(Claim) | Claim reference
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 1..1 | Identifier | GFE identifier of the originally submitted claim
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | S Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
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
preAuthRef |  | 0..* | string | Preauthorization reference
preAuthRefPeriod |  | 0..* | Period | Preauthorization in-effect period
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.
supportingInfo |  | 0..* | BackboneElement | Supporting 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 | Information instance identifier
category |  | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
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
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
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) |
item |  | 1..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:serviceDescription | S C | 0..1 | string | Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
careTeamSequence |  | 0..* | positiveInt | Applicable care team members
diagnosisSequence |  | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required)
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (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 C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
text | Σ | 0..1 | string | Plain text representation of the concept
modifier | S | 0..4 | CodeableConcept | Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (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 C | 0..* | Coding | Code defined by a terminology system Constraints: pct-cpt-display
text | Σ | 0..1 | string | Plain text representation of the concept
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 1..1 |  | This is the planned or estimated date(s)s of service
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
Slices for adjudication | S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category
adjudication: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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:medicalmanagement | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:submitted | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:memberliability | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:eligible | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefit | S | 0..1 | BackboneElement | Benefit 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
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 | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
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 | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
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
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
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
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
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
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category
adjudication: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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:medicalmanagement | S | 0..* | BackboneElement | Header-level adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:subjectToMedicalMgmt |  | 1..1 | CodeableConcept | Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalmanagement
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing Provider Network Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:renderingnetworkstatus | S | 0..1 | BackboneElement | Rendering Provider Network Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefitpaymentstatus | S | 0..1 | BackboneElement | Benefit Payment Status
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjustmentreason | S | 0..* | BackboneElement | Adjustment Reason
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 | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: PCT Adjustment Reason (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:submitted | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:memberliability | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: memberliability
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:eligible | S | 0..1 | BackboneElement | 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: eligible
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:benefit | S | 0..1 | BackboneElement | Benefit 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 |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefit
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
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
payment |  | 0..1 | BackboneElement | Payment Details
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
type |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
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)
allowed[x] | S | 1..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt S |
allowedMoney |  |  | Money S |
used[x] | S | 1..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt S |
usedMoney |  |  | Money S |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | required | Claim Type Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserve | Base | example | FundsReserve | 📍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.​claim.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​claim.identifier.type | Base | extensible | IdentifierType | 📍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 | required | PCT GFE NUBC Revenue Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.productOrService | Base | required | Claim Medical Product or Service Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | required | PCT GFE Item CPT - HCPCS Value Set | 📦2.0.1 | This IG
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 | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:submitted.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:memberliability.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:eligible.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​item.adjudication:benefit.​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.​adjudication.category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:medicalmanagement.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:medicalmanagement.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason | Base | required | PCT Payer Benefit Payment Status | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason | Base | required | PCT Adjustment Reason | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:submitted.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:memberliability.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:memberliability.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:eligible.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:eligible.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:benefit.​category | Base | extensible | PCT GFE Item Adjudication Value Set | 📦2.0.1 | This IG
ExplanationOfBenefit.​adjudication:benefit.​reason | Base | example | Adjudication Reason 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()`
pct-aeob-1 | error | ExplanationOfBenefit | Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) | `extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`
pct-aeob-2 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`
pct-aeob-3 | error | ExplanationOfBenefit | Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) | `adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`
pct-cpt-display | error | ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding | CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) | `system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 23 elements(4 nested mandatory elements)
Must-Support: 38 elements
Prohibited: 4 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 Practitioner (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner)
- 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/gfeReference
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
- http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
- 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.identifier
- The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
- The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication
- The element 1 is sliced based on the value of ExplanationOfBenefit.total

Maturity: 2

Other representations of profile: CSV, Excel, Schematron