Patient Cost Transparency Implementation Guide
2.0.2 - STU 2 United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Resource Profile: PCT Advanced EOB Summary

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary Version: 2.0.2
Standards status: Trial-use Maturity Level: 1 Computable Name: PCTAdvancedEOBSummary
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.5

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

Notes on Fields

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

Usages:

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 Differentials, Snapshots, and other representations.

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ExplanationOfBenefit.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    ExplanationOfBenefit.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.Slices for extension.extension:serviceDescription This element must be supported. 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ExplanationOfBenefit.Slices for extension.extension:outOfNetworkProviderInfo This element must be supported. 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ExplanationOfBenefit.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    ExplanationOfBenefit.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
    ExplanationOfBenefit.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
      "code" : "estimate-summary"
    }
  ]
}
    ExplanationOfBenefit.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.
    Required Pattern: predetermination (extensions allowed)
    ExplanationOfBenefit.patient This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) The recipient of the products and services
    ExplanationOfBenefit.billablePeriod This element is included in summaries. 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ExplanationOfBenefit.created This element is included in summaries. 1..1 dateTime The date and time this summary was generated.
    ExplanationOfBenefit.insurer This element is included in summaries. 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ExplanationOfBenefit.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ExplanationOfBenefit.provider.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable (extensions allowed)
    ExplanationOfBenefit.priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ExplanationOfBenefit.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.
    ExplanationOfBenefit.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
    ExplanationOfBenefit.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
    ExplanationOfBenefit.insurance.coverage This element is included in summaries. 1..1 Reference(PCT Coverage) Insurance information
    ExplanationOfBenefit.Slices for total This element is included in summaries. 3..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    ExplanationOfBenefit.Slices for total.total:All Slices Content/Rules for all slices
    ExplanationOfBenefit.Slices for total.total:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:All Slices.category This element must be supported. This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ExplanationOfBenefit.Slices for total.total:All Slices.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:submitted This element must be supported. This element is included in summaries. 1..1 BackboneElement Total provider submitted amount
    ExplanationOfBenefit.Slices for total.total:submitted.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:submitted.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "submitted"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:submitted.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:memberliability This element must be supported. This element is included in summaries. 1..1 BackboneElement Total member liability
    ExplanationOfBenefit.Slices for total.total:memberliability.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:memberliability.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
      "code" : "memberliability"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:memberliability.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:eligible This element must be supported. This element is included in summaries. 1..1 BackboneElement Total eligible amount
    ExplanationOfBenefit.Slices for total.total:eligible.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:eligible.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "eligible"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:eligible.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:innetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total in network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:innetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:innetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "innetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:innetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:outofnetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total out of network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:outofnetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:outofnetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "outofnetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:outofnetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:noncovered This element must be supported. This element is included in summaries. 0..1 BackboneElement Total noncovered amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:noncovered.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:noncovered.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
      "code" : "noncovered"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:noncovered.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:negotiated This element must be supported. This element is included in summaries. 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
    ExplanationOfBenefit.Slices for total.total:negotiated.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:negotiated.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "negotiated"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:negotiated.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:benefit This element must be supported. This element is included in summaries. 0..1 BackboneElement Total benefit amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:benefit.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:benefit.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "benefit"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:benefit.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.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.
    ExplanationOfBenefit.processNote.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.processNote.Slices for extension.extension:processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ExplanationOfBenefit.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitPeriod 1..1 Period When the benefits are applicable
    ExplanationOfBenefit.benefitBalance 1..* BackboneElement Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
    ExplanationOfBenefit.benefitBalance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ExplanationOfBenefit.benefitBalance.category.text This element must be supported. This element is included in summaries. 1..1 string Plain text representation of the concept
    ExplanationOfBenefit.benefitBalance.unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ExplanationOfBenefit.benefitBalance.term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ExplanationOfBenefit.benefitBalance.financial 1..* BackboneElement Benefit Summary
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension.extension:remaining This element must be supported. 0..1 unsignedInt This type must be supported. , Money This type must be supported. Benefit Remaining
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
    ExplanationOfBenefit.benefitBalance.financial.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.financial.type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x].allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x].used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​total:submitted.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:memberliability.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:eligible.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:innetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:outofnetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:noncovered.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:negotiated.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:benefit.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​benefitBalance.category Base required PCT benefitBalance.category codes 📦2.0.2 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 📦2.0.2 This IG

    Constraints

    Id Grade Path(s) Description Expression

    This structure is derived from ExplanationOfBenefit

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

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​benefitBalance.category Base required PCT benefitBalance.category codes 📦2.0.2 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 📦2.0.2 This IG
    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ExplanationOfBenefit.id This element is included in summaries. 0..1 id Logical id of this artifact
    ExplanationOfBenefit.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    ExplanationOfBenefit.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    ExplanationOfBenefit.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ExplanationOfBenefit.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
    ExplanationOfBenefit.contained 0..* Resource Contained, inline Resources
    ExplanationOfBenefit.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.Slices for extension.extension:serviceDescription This element must be supported. 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ExplanationOfBenefit.Slices for extension.extension:outOfNetworkProviderInfo This element must be supported. 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ExplanationOfBenefit.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    ExplanationOfBenefit.identifier 0..* Identifier Business Identifier for the resource
    ExplanationOfBenefit.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
    ExplanationOfBenefit.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
      "code" : "estimate-summary"
    }
  ]
}
    ExplanationOfBenefit.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.
    Required Pattern: predetermination (extensions allowed)
    ExplanationOfBenefit.patient This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) The recipient of the products and services
    ExplanationOfBenefit.billablePeriod This element is included in summaries. 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ExplanationOfBenefit.created This element is included in summaries. 1..1 dateTime The date and time this summary was generated.
    ExplanationOfBenefit.insurer This element is included in summaries. 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ExplanationOfBenefit.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ExplanationOfBenefit.provider.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.provider.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable (extensions allowed)
    ExplanationOfBenefit.priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ExplanationOfBenefit.related 0..* BackboneElement Prior or corollary claims
    ExplanationOfBenefit.related.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.related.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.related.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.related.claim 0..1 Reference(Claim) Reference to the related claim
    ExplanationOfBenefit.related.relationship 0..1 CodeableConcept How the reference claim is related
    Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
    ExplanationOfBenefit.related.reference 0..1 Identifier File or case reference
    ExplanationOfBenefit.claimResponse 0..1 Reference(ClaimResponse) Claim response reference
    ExplanationOfBenefit.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.
    ExplanationOfBenefit.disposition 0..1 string Disposition Message
    ExplanationOfBenefit.careTeam 0..* BackboneElement Care Team members
    ExplanationOfBenefit.careTeam.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.careTeam.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.careTeam.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.careTeam.sequence 1..1 positiveInt Order of care team
    ExplanationOfBenefit.careTeam.provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
    ExplanationOfBenefit.careTeam.responsible 0..1 boolean Indicator of the lead practitioner
    ExplanationOfBenefit.careTeam.role 0..1 CodeableConcept Function within the team
    Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
    ExplanationOfBenefit.careTeam.qualification 0..1 CodeableConcept Practitioner credential or specialization
    Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
    ExplanationOfBenefit.diagnosis 0..* BackboneElement Pertinent diagnosis information
    ExplanationOfBenefit.diagnosis.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.diagnosis.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.diagnosis.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.diagnosis.sequence 1..1 positiveInt Diagnosis instance identifier
    ExplanationOfBenefit.diagnosis.diagnosis[x] 1..1 Nature of illness or problem
    Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
    ExplanationOfBenefit.diagnosis.diagnosis[x].diagnosisCodeableConcept CodeableConcept
    ExplanationOfBenefit.diagnosis.diagnosis[x].diagnosisReference Reference(Condition)
    ExplanationOfBenefit.diagnosis.type 0..* CodeableConcept Timing or nature of the diagnosis
    Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
    ExplanationOfBenefit.diagnosis.onAdmission 0..1 CodeableConcept Present on admission
    Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
    ExplanationOfBenefit.diagnosis.packageCode 0..1 CodeableConcept Package billing code
    Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
    ExplanationOfBenefit.procedure 0..* BackboneElement Clinical procedures performed
    ExplanationOfBenefit.procedure.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.procedure.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.procedure.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.procedure.sequence 1..1 positiveInt Procedure instance identifier
    ExplanationOfBenefit.procedure.type 0..* CodeableConcept Category of Procedure
    Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
    ExplanationOfBenefit.procedure.date 0..1 dateTime When the procedure was performed
    ExplanationOfBenefit.procedure.procedure[x] 1..1 Specific clinical procedure
    Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
    ExplanationOfBenefit.procedure.procedure[x].procedureCodeableConcept CodeableConcept
    ExplanationOfBenefit.procedure.procedure[x].procedureReference Reference(Procedure)
    ExplanationOfBenefit.procedure.udi 0..* Reference(Device) Unique device identifier
    ExplanationOfBenefit.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
    ExplanationOfBenefit.insurance.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.insurance.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
    ExplanationOfBenefit.insurance.coverage This element is included in summaries. 1..1 Reference(PCT Coverage) Insurance information
    ExplanationOfBenefit.insurance.preAuthRef 0..* string Prior authorization reference number
    ExplanationOfBenefit.accident 0..1 BackboneElement Details of the event
    ExplanationOfBenefit.accident.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.accident.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.accident.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.accident.date 0..1 date When the incident occurred
    ExplanationOfBenefit.accident.type 0..1 CodeableConcept The nature of the accident
    Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc.
    ExplanationOfBenefit.accident.location[x] 0..1 Where the event occurred
    ExplanationOfBenefit.accident.location[x].locationAddress Address
    ExplanationOfBenefit.accident.location[x].locationReference Reference(Location)
    ExplanationOfBenefit.Slices for total This element is included in summaries. 3..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    ExplanationOfBenefit.Slices for total.total:All Slices Content/Rules for all slices
    ExplanationOfBenefit.Slices for total.total:All Slices.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:All Slices.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:All Slices.category This element must be supported. This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ExplanationOfBenefit.Slices for total.total:All Slices.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:submitted This element must be supported. This element is included in summaries. 1..1 BackboneElement Total provider submitted amount
    ExplanationOfBenefit.Slices for total.total:submitted.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:submitted.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:submitted.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:submitted.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "submitted"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:submitted.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:memberliability This element must be supported. This element is included in summaries. 1..1 BackboneElement Total member liability
    ExplanationOfBenefit.Slices for total.total:memberliability.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:memberliability.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:memberliability.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:memberliability.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
      "code" : "memberliability"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:memberliability.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:eligible This element must be supported. This element is included in summaries. 1..1 BackboneElement Total eligible amount
    ExplanationOfBenefit.Slices for total.total:eligible.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:eligible.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:eligible.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:eligible.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "eligible"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:eligible.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:innetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total in network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:innetwork.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:innetwork.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:innetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:innetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "innetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:innetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:outofnetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total out of network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:outofnetwork.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:outofnetwork.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:outofnetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:outofnetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "outofnetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:outofnetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:noncovered This element must be supported. This element is included in summaries. 0..1 BackboneElement Total noncovered amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:noncovered.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:noncovered.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:noncovered.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:noncovered.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
      "code" : "noncovered"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:noncovered.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:negotiated This element must be supported. This element is included in summaries. 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
    ExplanationOfBenefit.Slices for total.total:negotiated.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:negotiated.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:negotiated.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:negotiated.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "negotiated"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:negotiated.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:benefit This element must be supported. This element is included in summaries. 0..1 BackboneElement Total benefit amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:benefit.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:benefit.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:benefit.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:benefit.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "benefit"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:benefit.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.formCode 0..1 CodeableConcept Printed form identifier
    Binding: Form Codes (example): The forms codes.
    ExplanationOfBenefit.form 0..1 Attachment Printed reference or actual form
    ExplanationOfBenefit.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.
    ExplanationOfBenefit.processNote.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.processNote.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.processNote.Slices for extension.extension:processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ExplanationOfBenefit.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.processNote.number 0..1 positiveInt Note instance identifier
    ExplanationOfBenefit.processNote.type 0..1 code display | print | printoper
    Binding: NoteType (required): The presentation types of notes.
    ExplanationOfBenefit.processNote.text 0..1 string Note explanatory text
    ExplanationOfBenefit.processNote.language 0..1 CodeableConcept Language of the text
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ExplanationOfBenefit.benefitPeriod 1..1 Period When the benefits are applicable
    ExplanationOfBenefit.benefitBalance 1..* BackboneElement Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
    ExplanationOfBenefit.benefitBalance.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.benefitBalance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ExplanationOfBenefit.benefitBalance.category.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.category.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
    ExplanationOfBenefit.benefitBalance.category.text This element must be supported. This element is included in summaries. 1..1 string Plain text representation of the concept
    ExplanationOfBenefit.benefitBalance.excluded 0..1 boolean Excluded from the plan
    ExplanationOfBenefit.benefitBalance.name 0..1 string Short name for the benefit
    ExplanationOfBenefit.benefitBalance.description 0..1 string Description of the benefit or services covered
    ExplanationOfBenefit.benefitBalance.network 0..1 CodeableConcept In or out of network
    Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
    ExplanationOfBenefit.benefitBalance.unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ExplanationOfBenefit.benefitBalance.term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ExplanationOfBenefit.benefitBalance.financial 1..* BackboneElement Benefit Summary
    ExplanationOfBenefit.benefitBalance.financial.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension.extension:remaining This element must be supported. 0..1 unsignedInt This type must be supported. , Money This type must be supported. Benefit Remaining
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
    ExplanationOfBenefit.benefitBalance.financial.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.financial.type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x].allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x].used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​payee.type Base example PayeeType 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📍3.0.0 THO v7.1
    ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​total:submitted.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:memberliability.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:eligible.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:innetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:outofnetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:noncovered.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:negotiated.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:benefit.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    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 📦2.0.2 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 📦2.0.2 This IG

    Constraints

    Id Grade Path(s) Description Expression

    This structure is derived from ExplanationOfBenefit

    Summary

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

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

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

    Maturity: 1

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ExplanationOfBenefit.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    ExplanationOfBenefit.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.Slices for extension.extension:serviceDescription This element must be supported. 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ExplanationOfBenefit.Slices for extension.extension:outOfNetworkProviderInfo This element must be supported. 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ExplanationOfBenefit.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    ExplanationOfBenefit.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
    ExplanationOfBenefit.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
      "code" : "estimate-summary"
    }
  ]
}
    ExplanationOfBenefit.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.
    Required Pattern: predetermination (extensions allowed)
    ExplanationOfBenefit.patient This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) The recipient of the products and services
    ExplanationOfBenefit.billablePeriod This element is included in summaries. 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ExplanationOfBenefit.created This element is included in summaries. 1..1 dateTime The date and time this summary was generated.
    ExplanationOfBenefit.insurer This element is included in summaries. 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ExplanationOfBenefit.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ExplanationOfBenefit.provider.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable (extensions allowed)
    ExplanationOfBenefit.priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ExplanationOfBenefit.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.
    ExplanationOfBenefit.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
    ExplanationOfBenefit.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
    ExplanationOfBenefit.insurance.coverage This element is included in summaries. 1..1 Reference(PCT Coverage) Insurance information
    ExplanationOfBenefit.Slices for total This element is included in summaries. 3..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    ExplanationOfBenefit.Slices for total.total:All Slices Content/Rules for all slices
    ExplanationOfBenefit.Slices for total.total:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:All Slices.category This element must be supported. This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ExplanationOfBenefit.Slices for total.total:All Slices.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:submitted This element must be supported. This element is included in summaries. 1..1 BackboneElement Total provider submitted amount
    ExplanationOfBenefit.Slices for total.total:submitted.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:submitted.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "submitted"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:submitted.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:memberliability This element must be supported. This element is included in summaries. 1..1 BackboneElement Total member liability
    ExplanationOfBenefit.Slices for total.total:memberliability.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:memberliability.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
      "code" : "memberliability"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:memberliability.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:eligible This element must be supported. This element is included in summaries. 1..1 BackboneElement Total eligible amount
    ExplanationOfBenefit.Slices for total.total:eligible.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:eligible.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "eligible"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:eligible.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:innetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total in network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:innetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:innetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "innetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:innetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:outofnetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total out of network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:outofnetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:outofnetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "outofnetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:outofnetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:noncovered This element must be supported. This element is included in summaries. 0..1 BackboneElement Total noncovered amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:noncovered.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:noncovered.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
      "code" : "noncovered"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:noncovered.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:negotiated This element must be supported. This element is included in summaries. 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
    ExplanationOfBenefit.Slices for total.total:negotiated.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:negotiated.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "negotiated"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:negotiated.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:benefit This element must be supported. This element is included in summaries. 0..1 BackboneElement Total benefit amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:benefit.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:benefit.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "benefit"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:benefit.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.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.
    ExplanationOfBenefit.processNote.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.processNote.Slices for extension.extension:processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ExplanationOfBenefit.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitPeriod 1..1 Period When the benefits are applicable
    ExplanationOfBenefit.benefitBalance 1..* BackboneElement Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
    ExplanationOfBenefit.benefitBalance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ExplanationOfBenefit.benefitBalance.category.text This element must be supported. This element is included in summaries. 1..1 string Plain text representation of the concept
    ExplanationOfBenefit.benefitBalance.unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ExplanationOfBenefit.benefitBalance.term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ExplanationOfBenefit.benefitBalance.financial 1..* BackboneElement Benefit Summary
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension.extension:remaining This element must be supported. 0..1 unsignedInt This type must be supported. , Money This type must be supported. Benefit Remaining
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
    ExplanationOfBenefit.benefitBalance.financial.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.financial.type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x].allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x].used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​total:submitted.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:memberliability.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:eligible.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:innetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:outofnetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:noncovered.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:negotiated.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:benefit.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​benefitBalance.category Base required PCT benefitBalance.category codes 📦2.0.2 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 📦2.0.2 This IG

    Constraints

    Id Grade Path(s) Description Expression

    Differential View

    This structure is derived from ExplanationOfBenefit

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

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​benefitBalance.category Base required PCT benefitBalance.category codes 📦2.0.2 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 📦2.0.2 This IG

    Snapshot ViewView

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource
    ExplanationOfBenefit.id This element is included in summaries. 0..1 id Logical id of this artifact
    ExplanationOfBenefit.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    ExplanationOfBenefit.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    ExplanationOfBenefit.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ExplanationOfBenefit.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
    ExplanationOfBenefit.contained 0..* Resource Contained, inline Resources
    ExplanationOfBenefit.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.Slices for extension.extension:serviceDescription This element must be supported. 0..1 string Service Description
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
    ExplanationOfBenefit.Slices for extension.extension:outOfNetworkProviderInfo This element must be supported. 0..1 url In Network Provider Options Link
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
    ExplanationOfBenefit.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    ExplanationOfBenefit.identifier 0..* Identifier Business Identifier for the resource
    ExplanationOfBenefit.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
    ExplanationOfBenefit.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
    Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse",
      "code" : "estimate-summary"
    }
  ]
}
    ExplanationOfBenefit.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
    Binding: Use (required): Complete, proposed, exploratory, other.
    Required Pattern: predetermination (extensions allowed)
    ExplanationOfBenefit.patient This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) The recipient of the products and services
    ExplanationOfBenefit.billablePeriod This element is included in summaries. 1..1 Period The full Period of Care for all services or products included in the estimate from the first event to the last event.
    ExplanationOfBenefit.created This element is included in summaries. 1..1 dateTime The date and time this summary was generated.
    ExplanationOfBenefit.insurer This element is included in summaries. 1..1 Reference(PCT Organization) Party responsible for reimbursement
    ExplanationOfBenefit.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
    ExplanationOfBenefit.provider.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.provider.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason 1..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ExplanationOfBenefit.provider.Slices for extension.extension:dataAbsentReason.value[x] 1..1 code Value of extension
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable (extensions allowed)
    ExplanationOfBenefit.priority 0..1 CodeableConcept Desired processing urgency
    Binding: ProcessPriorityCodes (required)
    ExplanationOfBenefit.related 0..* BackboneElement Prior or corollary claims
    ExplanationOfBenefit.related.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.related.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.related.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.related.claim 0..1 Reference(Claim) Reference to the related claim
    ExplanationOfBenefit.related.relationship 0..1 CodeableConcept How the reference claim is related
    Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
    ExplanationOfBenefit.related.reference 0..1 Identifier File or case reference
    ExplanationOfBenefit.claimResponse 0..1 Reference(ClaimResponse) Claim response reference
    ExplanationOfBenefit.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
    Binding: ClaimProcessingCodes (required): The result of the claim processing.
    ExplanationOfBenefit.disposition 0..1 string Disposition Message
    ExplanationOfBenefit.careTeam 0..* BackboneElement Care Team members
    ExplanationOfBenefit.careTeam.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.careTeam.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.careTeam.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.careTeam.sequence 1..1 positiveInt Order of care team
    ExplanationOfBenefit.careTeam.provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
    ExplanationOfBenefit.careTeam.responsible 0..1 boolean Indicator of the lead practitioner
    ExplanationOfBenefit.careTeam.role 0..1 CodeableConcept Function within the team
    Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
    ExplanationOfBenefit.careTeam.qualification 0..1 CodeableConcept Practitioner credential or specialization
    Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
    ExplanationOfBenefit.diagnosis 0..* BackboneElement Pertinent diagnosis information
    ExplanationOfBenefit.diagnosis.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.diagnosis.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.diagnosis.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.diagnosis.sequence 1..1 positiveInt Diagnosis instance identifier
    ExplanationOfBenefit.diagnosis.diagnosis[x] 1..1 Nature of illness or problem
    Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
    ExplanationOfBenefit.diagnosis.diagnosis[x].diagnosisCodeableConcept CodeableConcept
    ExplanationOfBenefit.diagnosis.diagnosis[x].diagnosisReference Reference(Condition)
    ExplanationOfBenefit.diagnosis.type 0..* CodeableConcept Timing or nature of the diagnosis
    Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
    ExplanationOfBenefit.diagnosis.onAdmission 0..1 CodeableConcept Present on admission
    Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
    ExplanationOfBenefit.diagnosis.packageCode 0..1 CodeableConcept Package billing code
    Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
    ExplanationOfBenefit.procedure 0..* BackboneElement Clinical procedures performed
    ExplanationOfBenefit.procedure.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.procedure.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.procedure.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.procedure.sequence 1..1 positiveInt Procedure instance identifier
    ExplanationOfBenefit.procedure.type 0..* CodeableConcept Category of Procedure
    Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
    ExplanationOfBenefit.procedure.date 0..1 dateTime When the procedure was performed
    ExplanationOfBenefit.procedure.procedure[x] 1..1 Specific clinical procedure
    Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
    ExplanationOfBenefit.procedure.procedure[x].procedureCodeableConcept CodeableConcept
    ExplanationOfBenefit.procedure.procedure[x].procedureReference Reference(Procedure)
    ExplanationOfBenefit.procedure.udi 0..* Reference(Device) Unique device identifier
    ExplanationOfBenefit.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
    ExplanationOfBenefit.insurance.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.insurance.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
    ExplanationOfBenefit.insurance.coverage This element is included in summaries. 1..1 Reference(PCT Coverage) Insurance information
    ExplanationOfBenefit.insurance.preAuthRef 0..* string Prior authorization reference number
    ExplanationOfBenefit.accident 0..1 BackboneElement Details of the event
    ExplanationOfBenefit.accident.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.accident.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.accident.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.accident.date 0..1 date When the incident occurred
    ExplanationOfBenefit.accident.type 0..1 CodeableConcept The nature of the accident
    Binding: ActIncidentCode (3.0.0) (extensible): Type of accident: work place, auto, etc.
    ExplanationOfBenefit.accident.location[x] 0..1 Where the event occurred
    ExplanationOfBenefit.accident.location[x].locationAddress Address
    ExplanationOfBenefit.accident.location[x].locationReference Reference(Location)
    ExplanationOfBenefit.Slices for total This element is included in summaries. 3..* BackboneElement Adjudication totals
    Slice: Unordered, Open by value:category

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    ExplanationOfBenefit.Slices for total.total:All Slices Content/Rules for all slices
    ExplanationOfBenefit.Slices for total.total:All Slices.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:All Slices.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:All Slices.category This element must be supported. This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: PCT Total Value Set (extensible)
    ExplanationOfBenefit.Slices for total.total:All Slices.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:submitted This element must be supported. This element is included in summaries. 1..1 BackboneElement Total provider submitted amount
    ExplanationOfBenefit.Slices for total.total:submitted.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:submitted.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:submitted.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:submitted.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "submitted"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:submitted.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:memberliability This element must be supported. This element is included in summaries. 1..1 BackboneElement Total member liability
    ExplanationOfBenefit.Slices for total.total:memberliability.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:memberliability.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:memberliability.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:memberliability.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
      "code" : "memberliability"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:memberliability.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:eligible This element must be supported. This element is included in summaries. 1..1 BackboneElement Total eligible amount
    ExplanationOfBenefit.Slices for total.total:eligible.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:eligible.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:eligible.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:eligible.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "eligible"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:eligible.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:innetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total in network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:innetwork.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:innetwork.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:innetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:innetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "innetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:innetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:outofnetwork This element must be supported. This element is included in summaries. 0..1 BackboneElement Total out of network amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:outofnetwork.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:outofnetwork.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:outofnetwork.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:outofnetwork.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "outofnetwork"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:outofnetwork.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:noncovered This element must be supported. This element is included in summaries. 0..1 BackboneElement Total noncovered amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:noncovered.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:noncovered.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:noncovered.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:noncovered.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
      "code" : "noncovered"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:noncovered.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:negotiated This element must be supported. This element is included in summaries. 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
    ExplanationOfBenefit.Slices for total.total:negotiated.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:negotiated.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:negotiated.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:negotiated.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
      "code" : "negotiated"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:negotiated.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.Slices for total.total:benefit This element must be supported. This element is included in summaries. 0..1 BackboneElement Total benefit amount - only include when total type is applicable
    ExplanationOfBenefit.Slices for total.total:benefit.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.Slices for total.total:benefit.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.Slices for total.total:benefit.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.Slices for total.total:benefit.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
    Binding: AdjudicationValueCodes (example): The adjudication codes.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
      "code" : "benefit"
    }
  ]
}
    ExplanationOfBenefit.Slices for total.total:benefit.amount This element is included in summaries. 1..1 Money Financial total for the category
    ExplanationOfBenefit.formCode 0..1 CodeableConcept Printed form identifier
    Binding: Form Codes (example): The forms codes.
    ExplanationOfBenefit.form 0..1 Attachment Printed reference or actual form
    ExplanationOfBenefit.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.
    ExplanationOfBenefit.processNote.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.processNote.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.processNote.Slices for extension.extension:processNoteClass 0..1 CodeableConcept ProcessNote Class
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
    Binding: PCT AEOB Process Note Types (required)
    ExplanationOfBenefit.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.processNote.number 0..1 positiveInt Note instance identifier
    ExplanationOfBenefit.processNote.type 0..1 code display | print | printoper
    Binding: NoteType (required): The presentation types of notes.
    ExplanationOfBenefit.processNote.text 0..1 string Note explanatory text
    ExplanationOfBenefit.processNote.language 0..1 CodeableConcept Language of the text
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    ExplanationOfBenefit.benefitPeriod 1..1 Period When the benefits are applicable
    ExplanationOfBenefit.benefitBalance 1..* BackboneElement Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
    ExplanationOfBenefit.benefitBalance.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.extension 0..* Extension Additional content defined by implementations
    ExplanationOfBenefit.benefitBalance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.category 1..1 CodeableConcept Benefit classification
    Binding: PCT benefitBalance.category codes (required)
    ExplanationOfBenefit.benefitBalance.category.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.category.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
    ExplanationOfBenefit.benefitBalance.category.text This element must be supported. This element is included in summaries. 1..1 string Plain text representation of the concept
    ExplanationOfBenefit.benefitBalance.excluded 0..1 boolean Excluded from the plan
    ExplanationOfBenefit.benefitBalance.name 0..1 string Short name for the benefit
    ExplanationOfBenefit.benefitBalance.description 0..1 string Description of the benefit or services covered
    ExplanationOfBenefit.benefitBalance.network 0..1 CodeableConcept In or out of network
    Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
    ExplanationOfBenefit.benefitBalance.unit 1..1 CodeableConcept Individual or family
    Binding: UnitTypeCodes (required)
    ExplanationOfBenefit.benefitBalance.term 1..1 CodeableConcept Annual or lifetime
    Binding: BenefitTermCodes (required)
    ExplanationOfBenefit.benefitBalance.financial 1..* BackboneElement Benefit Summary
    ExplanationOfBenefit.benefitBalance.financial.id 0..1 string Unique id for inter-element referencing
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ExplanationOfBenefit.benefitBalance.financial.Slices for extension.extension:remaining This element must be supported. 0..1 unsignedInt This type must be supported. , Money This type must be supported. Benefit Remaining
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
    ExplanationOfBenefit.benefitBalance.financial.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    ExplanationOfBenefit.benefitBalance.financial.type 1..1 CodeableConcept Benefit classification
    Binding: PCT Financial Type Value Set (required)
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x] 1..1 Money Benefits allowed
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for allowed[x].allowed[x]:allowedMoney 1..1 Money Benefits allowed
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x] 1..1 Money Benefits used
    Slice: Unordered, Closed by type:$this
    ExplanationOfBenefit.benefitBalance.financial.Slices for used[x].used[x]:usedMoney 1..1 Money Benefits used

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​provider.extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
    ExplanationOfBenefit.​related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​payee.type Base example PayeeType 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📍3.0.0 THO v7.1
    ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total.category Base extensible PCT Total Value Set 📦2.0.2 This IG
    ExplanationOfBenefit.​total:submitted.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:memberliability.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:eligible.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:innetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:outofnetwork.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:noncovered.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:negotiated.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    ExplanationOfBenefit.​total:benefit.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
    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 📦2.0.2 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 📦2.0.2 This IG

    Constraints

    Id Grade Path(s) Description Expression

    This structure is derived from ExplanationOfBenefit

    Summary

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

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

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

    Maturity: 1

     

    Other representations of profile: CSV, Excel, Schematron