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

Notes on Fields

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

Examples

Example 1 – Estimation based on current benefit period

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

Example 2 – Estimation based on a future benefit period

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

Changes since version 1.1.0:

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

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

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ExplanationOfBenefit.​identifier:uniqueclaimid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​status	Base	required	ExplanationOfBenefitStatus	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​type	Base	required	Claim Type Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​use	Base	required	Use	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​priority	Base	required	Process Priority Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​claim.identifier.use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​outcome	Base	required	Claim Processing Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.revenue	Base	required	PCT GFE NUBC Revenue Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.productOrService	Base	required	Claim Medical Product or Service Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.modifier	Base	required	PCT GFE Item CPT - HCPCS Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:memberliability.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:eligible.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefit.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:medicalmanagement.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:submitted.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:memberliability.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:eligible.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:benefit.​category	Base	example	Adjudication Value 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
pct-aeob-1	error	ExplanationOfBenefit	Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations)	extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()
pct-aeob-2	error	ExplanationOfBenefit	Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)	adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()
pct-aeob-3	error	ExplanationOfBenefit	Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)	adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()
pct-cpt-display	error	ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding	CPT codes require a display value (CPT Consumer Friendly Descriptors recommended)	system = 'http://www.ama-assn.org/go/cpt' implies display.exists()

This structure is derived from ExplanationOfBenefit

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

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
ExplanationOfBenefit.​type	Base	required	Claim Type Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​priority	Base	required	Process Priority Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​item.revenue	Base	required	PCT GFE NUBC Revenue Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.productOrService	Base	required	Claim Medical Product or Service Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.modifier	Base	required	PCT GFE Item CPT - HCPCS Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
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

Constraints

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

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

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ExplanationOfBenefit.​language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​status	Base	required	ExplanationOfBenefitStatus	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​type	Base	required	Claim Type Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​subType	Base	example	Example Claim SubType Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​use	Base	required	Use	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​priority	Base	required	Process Priority Codes	📦4.0.1	FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested	Base	example	FundsReserve	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​fundsReserve	Base	example	FundsReserve	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​related.relationship	Base	example	Example Related Claim Relationship Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​payee.type	Base	example	PayeeType	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​claim.type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​claim.identifier.use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​claim.identifier.type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​outcome	Base	required	Claim Processing Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​careTeam.role	Base	example	Claim Care Team Role Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​careTeam.qualification	Base	example	Example Provider Qualification Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​supportingInfo.category	Base	example	Claim Information Category Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​supportingInfo.code	Base	example	Exception Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason	Base	example	Missing Tooth Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x]	Base	example	ICD-10 Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​diagnosis.type	Base	example	Example Diagnosis Type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission	Base	example	Example Diagnosis on Admission Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode	Base	example	Example Diagnosis Related Group Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​procedure.type	Base	example	Example Procedure Type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x]	Base	example	ICD-10 Procedure Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​accident.type	Base	extensible	ActIncidentCode	📍3.0.0	THO v7.1
ExplanationOfBenefit.​item.revenue	Base	required	PCT GFE NUBC Revenue Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.category	Base	example	Benefit Category Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.productOrService	Base	required	Claim Medical Product or Service Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.modifier	Base	required	PCT GFE Item CPT - HCPCS Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.bodySite	Base	example	Oral Site Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.subSite	Base	example	Surface Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:medicalmanagement.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
ExplanationOfBenefit.​item.adjudication:submitted.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:submitted.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:memberliability.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:memberliability.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:eligible.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:eligible.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefit.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.adjudication:benefit.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.revenue	Base	example	Example Revenue Center Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.category	Base	example	Benefit Category Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue	Base	example	Example Revenue Center Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category	Base	example	Benefit Category Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.bodySite	Base	example	Oral Site Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.subSite	Base	example	Surface Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication.category	Base	extensible	PCT GFE Item Adjudication Value Set	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:medicalmanagement.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:medicalmanagement.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:benefitpaymentstatus.​reason	Base	required	PCT Payer Benefit Payment Status	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:adjustmentreason.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:adjustmentreason.​reason	Base	required	PCT Adjustment Reason	📦2.0.2	This IG
ExplanationOfBenefit.​adjudication:submitted.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:submitted.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:memberliability.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:memberliability.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:eligible.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:eligible.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:benefit.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​adjudication:benefit.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ExplanationOfBenefit.​total.category	Base	extensible	PCT Total Value Set	📦2.0.2	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
pct-aeob-1	error	ExplanationOfBenefit	Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations)	extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()
pct-aeob-2	error	ExplanationOfBenefit	Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)	adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()
pct-aeob-3	error	ExplanationOfBenefit	Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)	adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()
pct-cpt-display	error	ExplanationOfBenefit.item.productOrService.coding, ExplanationOfBenefit.item.modifier.coding	CPT codes require a display value (CPT Consumer Friendly Descriptors recommended)	system = 'http://www.ama-assn.org/go/cpt' implies display.exists()