Notes on Fields

• The estimated service date, when available at the header level, is placed in Claim.billablePeriod. If the estimated date of service is available at the line level it is placed in Claim.item.serviced[x].

Examples of .providerEventMethodology usage examples below:

Example 1 – A provider is offering both a surgical and a drug therapy-based option to the patient. The provider can add text such as "Surgical care option" and "Drug therapy option" to the GFE so that the patient could easily understand the options without having to understand different CPT codes.

Example 2 – A provider added services to a previously submitted GFE. They would be able to add "Added physical therapist on Sep 18, ignore estimates submitted on Sep 17".

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

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints
Claim			Claim
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
gfeSubmitter		1..1	Reference(PCT Organization | PCT Practitioner)	The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter
gfeServiceLinkingInfo	S	0..1	(Complex)	GFE Service Linking Information URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo
providerEventMethodology	S	0..1	string	Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
gfeDisclaimer	S	0..*	string	Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer
Slices for identifier		1..*	Identifier	Business Identifier for claim Slice: Unordered, Open by pattern:type
identifier:PLAC		1..1	Identifier	Provider Assigned Identifier for GFE Claim
type		1..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: PLAC
display		1..1	string	Representation defined by the system Fixed Value: Placer Identifier
system	S	0..1	uri	The namespace for the identifier value
value		1..1	string	The value that is unique
identifier:INTER		0..*	Identifier	Intermediary System Identifier
type		1..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: professional
use		1..1	code	claim | preauthorization | predetermination Required Pattern: predetermination
patient		1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
insurer		1..1	Reference(PCT Organization)	Target
provider		1..1	Reference(PCT Organization | PCT Practitioner)	Billing provider - party responsible for the GFE
extension		1..*	Extension	Extension
providerTaxonomy		1..1	CodeableConcept	Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible)
consentForBalanceBilling	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling
priority		1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (required)
payee	S	0..1	BackboneElement	Recipient of benefits payable
party		0..1	Reference(PCT Practitioner | PCT Organization)	Recipient reference
referral
extension		1..*	Extension	Extension
referralNumber		1..1	string	Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by pattern:role
careTeam:All Slices				Content/Rules for all slices
provider		1..1	Reference(PCT Practitioner | PCT Organization)	Practitioner or organization
role		1..1	CodeableConcept	Function within the team Binding: PCT Care Team Role Value Set (required)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: US Core Provider Role (NUCC) (required)
careTeam:rendering		0..*	BackboneElement	Members of the care team
role		0..1	CodeableConcept	Function within the team Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rendering
qualification		1..1	CodeableConcept	Practitioner credential or specialization - must provide a taxonomy code for the Professional case
careTeam:referring		0..1	BackboneElement	Members of the care team
role		0..1	CodeableConcept	Function within the team Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
code		1..1	code	Symbol in syntax defined by the system Fixed Value: referring
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
category		1..1	CodeableConcept	Classification of the supplied information Binding: PCT Supporting Info Type Value Set (extensible)
supportingInfo:serviceFacility	S	0..1	BackboneElement	Service Facility
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: servicefacility
Slices for value[x]		1..1	Reference(Resource)	Data to be provided Slice: Unordered, Open by type:$this
value[x]:valueReference		1..1	Reference(PCT Organization)	Data to be provided
supportingInfo:claimFrequency	S	0..1	BackboneElement	Claim Frequency
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: claimFrequency
code		1..1	CodeableConcept	Type of information Binding: PCT GFE Frequency Code Value Set (required)
Slices for diagnosis	S	1..*	BackboneElement	Pertinent diagnosis information Slice: Unordered, Open by pattern:type
diagnosis:All Slices				Content/Rules for all slices
type	S	0..*	CodeableConcept	Timing or nature of the diagnosis Binding: PCT Diagnosis Type Value Set (required)
diagnosis:principal		1..1	BackboneElement	Pertinent diagnosis information
sequence		1..1	positiveInt	Diagnosis instance identifier Required Pattern: 1
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
code		1..1	code	Symbol in syntax defined by the system Fixed Value: principal
diagnosis:other	S	0..11	BackboneElement	Pertinent diagnosis information
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: other
Slices for procedure	S	0..*	BackboneElement	Clinical procedures performed Slice: Unordered, Open by pattern:type
procedure:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
type	S	0..*	CodeableConcept	Category of Procedure Binding: PCT Procedure Type Value Set (required)
procedure:anesthesiaRelated	S	0..2	BackboneElement	Clinical procedures performed
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
type		1..1	CodeableConcept	Category of Procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: procedureRequiringAnesthesia
procedure[x]		1..1	CodeableConcept	Specific clinical procedure Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required)
procedure:other	S	0..24	BackboneElement	Clinical procedures performed
insurance
coverage		1..1	Reference(PCT Coverage)	Insurance information
preAuthRef		0..2	string	Prior authorization reference number
accident
location[x]		0..1	Address	Where the event occurred
country		0..1	string	Country (e.g. can be ISO 3166 2 or 3 letter code) Binding: Iso3166-1-2 (required)
item		1..50	BackboneElement	Product or service provided
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
referralNumber	S	0..11	string	Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
gfeBillingProviderLineItemCtrlNum	S	0..1	Identifier	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
ProviderEventMethodology	S	0..1	string	Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
modifier	S	0..4	CodeableConcept	Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
serviced[x]	S	1..1	date, Period	This is the planned or estimated date(s)s of service
location[x]		1..1	CodeableConcept	Place of service or where product was supplied Binding: PCT GFE CMS Place of Service Value Set (required)
quantity		1..1	SimpleQuantity	Count of products or services
unitPrice		1..1	Money	Fee, charge or cost per item
net		1..1	Money	Total charge amount for the service line
detail	S	0..*	BackboneElement	Drug Identification Information
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
total		1..1	Money	Total GFE Charges Submitted
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Claim.priority	required	ProcessPriorityCodes
Claim.careTeam.role	required	PCTCareTeamRoleVS
Claim.careTeam.qualification	required	USCoreProviderRoleNucc
Claim.supportingInfo.category	extensible	PCTSupportingInfoTypeVS (a valid code from PCT GFE Supporting Info Type Code System)
Claim.supportingInfo:claimFrequency.code	required	PCTGFEFrequencyVS (a valid code from PCT GFE Frequency Code System)
Claim.diagnosis.type	required	PCTDiagnosisTypeVS
Claim.diagnosis:principal.diagnosis[x]	required	PCTDiagnosticCodes
Claim.diagnosis:other.diagnosis[x]	required	PCTDiagnosticCodes
Claim.procedure.type	required	PCTProcedureTypeVS
Claim.procedure:anesthesiaRelated.procedure[x]	required	PCTProcedureSurgicalCodes
Claim.accident.location[x].country	required	Iso3166-1-2
Claim.item.productOrService	required	USClaimMedicalProductOrServiceCodes
Claim.item.modifier	required	PCTGFEItemCptHcpcsVS
Claim.item.location[x]	required	PCTGFECMSPOS
Claim.item.detail.productOrService	required	USClaimMedicalProductOrServiceCodes

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
gfeSubmitter		1..1	Reference(PCT Organization | PCT Practitioner)	The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter
gfeServiceLinkingInfo	S	0..1	(Complex)	GFE Service Linking Information URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo
providerEventMethodology	S	0..1	string	Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
gfeDisclaimer	S	0..*	string	Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier		1..*	Identifier	Business Identifier for claim Slice: Unordered, Open by pattern:type
identifier:PLAC		1..1	Identifier	Provider Assigned Identifier for GFE Claim
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: PLAC
display		1..1	string	Representation defined by the system Fixed Value: Placer Identifier
system	SΣ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
identifier:INTER		0..*	Identifier	Intermediary System Identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: professional
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
insurer	Σ	1..1	Reference(PCT Organization)	Target
provider	Σ	1..1	Reference(PCT Organization | PCT Practitioner)	Billing provider - party responsible for the GFE
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
providerTaxonomy		1..1	CodeableConcept	Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible)
consentForBalanceBilling	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (required)
payee	S	0..1	BackboneElement	Recipient of benefits payable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(PCT Practitioner | PCT Organization)	Recipient reference
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by pattern:role
careTeam:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(PCT Practitioner | PCT Organization)	Practitioner or organization
role		1..1	CodeableConcept	Function within the team Binding: PCT Care Team Role Value Set (required)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: US Core Provider Role (NUCC) (required)
careTeam:rendering		0..*	BackboneElement	Members of the care team
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rendering
qualification		1..1	CodeableConcept	Practitioner credential or specialization - must provide a taxonomy code for the Professional case Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:referring		0..1	BackboneElement	Members of the care team
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
code		1..1	code	Symbol in syntax defined by the system Fixed Value: referring
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: PCT Supporting Info Type Value Set (extensible)
supportingInfo:serviceFacility	S	0..1	BackboneElement	Service Facility
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: servicefacility
Slices for value[x]		1..1	Reference(Resource)	Data to be provided Slice: Unordered, Closed by type:$this
value[x]:valueReference		1..1	Reference(PCT Organization)	Data to be provided
supportingInfo:claimFrequency	S	0..1	BackboneElement	Claim Frequency
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: claimFrequency
code		1..1	CodeableConcept	Type of information Binding: PCT GFE Frequency Code Value Set (required)
Slices for diagnosis	S	1..*	BackboneElement	Pertinent diagnosis information Slice: Unordered, Open by pattern:type
diagnosis:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type	S	0..*	CodeableConcept	Timing or nature of the diagnosis Binding: PCT Diagnosis Type Value Set (required)
diagnosis:principal		1..1	BackboneElement	Pertinent diagnosis information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier Required Pattern: 1
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
code		1..1	code	Symbol in syntax defined by the system Fixed Value: principal
diagnosis:other	S	0..11	BackboneElement	Pertinent diagnosis information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: other
Slices for procedure	S	0..*	BackboneElement	Clinical procedures performed Slice: Unordered, Open by pattern:type
procedure:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type	S	0..*	CodeableConcept	Category of Procedure Binding: PCT Procedure Type Value Set (required)
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
procedure:anesthesiaRelated	S	0..2	BackboneElement	Clinical procedures performed
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		1..1	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: procedureRequiringAnesthesia
procedure[x]		1..1	CodeableConcept	Specific clinical procedure Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required)
procedure:other	S	0..24	BackboneElement	Clinical procedures performed
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
insurance	Σ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information
preAuthRef		0..2	string	Prior authorization reference number
item		1..50	BackboneElement	Product or service provided
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
referralNumber	S	0..11	string	Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
gfeBillingProviderLineItemCtrlNum	S	0..1	Identifier	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
ProviderEventMethodology	S	0..1	string	Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
modifier	S	0..4	CodeableConcept	Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
serviced[x]	S	1..1		This is the planned or estimated date(s)s of service
servicedDate			date
servicedPeriod			Period
location[x]		1..1	CodeableConcept	Place of service or where product was supplied Binding: PCT GFE CMS Place of Service Value Set (required)
quantity		1..1	SimpleQuantity	Count of products or services
unitPrice		1..1	Money	Fee, charge or cost per item
net		1..1	Money	Total charge amount for the service line
detail	S	0..*	BackboneElement	Drug Identification Information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
total		1..1	Money	Total GFE Charges Submitted
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.identifier:PLAC.use	required	IdentifierUse
Claim.identifier:PLAC.type	extensible	Pattern: PLAC("Placer Identifier")
Claim.identifier:INTER.use	required	IdentifierUse
Claim.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier")
Claim.status	required	FinancialResourceStatusCodes
Claim.type	extensible	Pattern: professional
Claim.use	required	Pattern: predetermination
Claim.priority	required	ProcessPriorityCodes
Claim.payee.type	example	Claim Payee Type Codes
Claim.careTeam.role	required	PCTCareTeamRoleVS
Claim.careTeam.qualification	required	USCoreProviderRoleNucc
Claim.careTeam:rendering.role	example	Pattern: rendering
Claim.careTeam:rendering.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:referring.role	example	Pattern: referring
Claim.supportingInfo.category	extensible	PCTSupportingInfoTypeVS (a valid code from PCT GFE Supporting Info Type Code System)
Claim.supportingInfo:serviceFacility.category	example	Pattern: servicefacility
Claim.supportingInfo:claimFrequency.category	example	Pattern: claimFrequency
Claim.supportingInfo:claimFrequency.code	required	PCTGFEFrequencyVS (a valid code from PCT GFE Frequency Code System)
Claim.diagnosis.diagnosis[x]	example	ICD-10Codes
Claim.diagnosis.type	required	PCTDiagnosisTypeVS
Claim.diagnosis:principal.diagnosis[x]	required	PCTDiagnosticCodes
Claim.diagnosis:principal.type	example	Pattern: principal
Claim.diagnosis:other.diagnosis[x]	required	PCTDiagnosticCodes
Claim.diagnosis:other.type	example	Pattern: other
Claim.procedure.type	required	PCTProcedureTypeVS
Claim.procedure.procedure[x]	example	ICD-10ProcedureCodes
Claim.procedure:anesthesiaRelated.type	example	Pattern: procedureRequiringAnesthesia
Claim.procedure:anesthesiaRelated.procedure[x]	required	PCTProcedureSurgicalCodes
Claim.procedure:other.procedure[x]	example	ICD-10ProcedureCodes
Claim.item.productOrService	required	USClaimMedicalProductOrServiceCodes
Claim.item.modifier	required	PCTGFEItemCptHcpcsVS
Claim.item.location[x]	required	PCTGFECMSPOS
Claim.item.detail.productOrService	required	USClaimMedicalProductOrServiceCodes

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
gfeSubmitter		1..1	Reference(PCT Organization | PCT Practitioner)	The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter
gfeServiceLinkingInfo	S	0..1	(Complex)	GFE Service Linking Information URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo
providerEventMethodology	S	0..1	string	Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
gfeDisclaimer	S	0..*	string	Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier		1..*	Identifier	Business Identifier for claim Slice: Unordered, Open by pattern:type
identifier:PLAC		1..1	Identifier	Provider Assigned Identifier for GFE Claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: PLAC
display		1..1	string	Representation defined by the system Fixed Value: Placer Identifier
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	SΣ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
identifier:INTER		0..*	Identifier	Intermediary System Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: INTER
display		1..1	string	Representation defined by the system Fixed Value: Intermediary System Identifier
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: professional
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: predetermination
patient	Σ	1..1	Reference(HRex Patient Demographics)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	Σ	1..1	Reference(PCT Organization)	Target
provider	Σ	1..1	Reference(PCT Organization | PCT Practitioner)	Billing provider - party responsible for the GFE
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
providerTaxonomy		1..1	CodeableConcept	Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: US Core Provider Role (NUCC) (extensible)
consentForBalanceBilling	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (required)
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee	S	0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(PCT Practitioner | PCT Organization)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
referralNumber		1..1	string	Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
facility		0..1	Reference(Location)	Servicing facility
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by pattern:role
careTeam:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(PCT Practitioner | PCT Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		1..1	CodeableConcept	Function within the team Binding: PCT Care Team Role Value Set (required)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: US Core Provider Role (NUCC) (required)
careTeam:rendering		0..*	BackboneElement	Members of the care team
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rendering
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
qualification		1..1	CodeableConcept	Practitioner credential or specialization - must provide a taxonomy code for the Professional case Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:referring		0..1	BackboneElement	Members of the care team
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: referring
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: PCT Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:serviceFacility	S	0..1	BackboneElement	Service Facility
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: servicefacility
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
Slices for value[x]		1..1	Reference(Resource)	Data to be provided Slice: Unordered, Closed by type:$this
value[x]:valueReference		1..1	Reference(PCT Organization)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:claimFrequency	S	0..1	BackboneElement	Claim Frequency
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: claimFrequency
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		1..1	CodeableConcept	Type of information Binding: PCT GFE Frequency Code Value Set (required)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
Slices for diagnosis	S	1..*	BackboneElement	Pertinent diagnosis information Slice: Unordered, Open by pattern:type
diagnosis:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type	S	0..*	CodeableConcept	Timing or nature of the diagnosis Binding: PCT Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
diagnosis:principal		1..1	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier Required Pattern: 1
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-diagnosistype
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: principal
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
diagnosis:other	S	0..11	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1	CodeableConcept	Nature of illness or problem Binding: PCT ICD-10 Diagnostic Codes (required)
type		1..1	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: other
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
Slices for procedure	S	0..*	BackboneElement	Clinical procedures performed Slice: Unordered, Open by pattern:type
procedure:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type	S	0..*	CodeableConcept	Category of Procedure Binding: PCT Procedure Type Value Set (required)
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
procedure:anesthesiaRelated	S	0..2	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		1..1	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: procedureRequiringAnesthesia
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1	CodeableConcept	Specific clinical procedure Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required)
udi		0..*	Reference(Device)	Unique device identifier
procedure:other	S	0..24	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	Σ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	Σ	1..1	Reference(PCT Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..2	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		1..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1	Address	Where the event occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	home | work | temp | old | billing - purpose of this address Binding: AddressUse (required): The use of an address. Example General: home
type	Σ	0..1	code	postal | physical | both Binding: AddressType (required): The type of an address (physical / postal). Example General: both
text	Σ	0..1	string	Text representation of the address Example General: 137 Nowhere Street, Erewhon 9132
line	Σ	0..*	string	Street name, number, direction & P.O. Box etc. This repeating element order: The order in which lines should appear in an address label Example General: 137 Nowhere Street
city	Σ	0..1	string	Name of city, town etc. Example General: Erewhon
district	Σ	0..1	string	District name (aka county) Example General: Madison
state	Σ	0..1	string	Sub-unit of country (abbreviations ok)
postalCode	Σ	0..1	string	Postal code for area Example General: 9132
country	Σ	0..1	string	Country (e.g. can be ISO 3166 2 or 3 letter code) Binding: Iso3166-1-2 (required)
period	Σ	0..1	Period	Time period when address was/is in use Example General: {"start":"2010-03-23","end":"2010-07-01"}
item		1..50	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
referralNumber	S	0..11	string	Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber
gfeBillingProviderLineItemCtrlNum	S	0..1	Identifier	Extension URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum
serviceDescription		1..1	string	Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
ProviderEventMethodology	S	0..1	string	Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
modifier	S	0..4	CodeableConcept	Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	1..1		This is the planned or estimated date(s)s of service
servicedDate			date
servicedPeriod			Period
location[x]		1..1	CodeableConcept	Place of service or where product was supplied Binding: PCT GFE CMS Place of Service Value Set (required)
quantity		1..1	SimpleQuantity	Count of products or services
unitPrice		1..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		1..1	Money	Total charge amount for the service line
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail	S	0..*	BackboneElement	Drug Identification Information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required)
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		1..1	Money	Total GFE Charges Submitted
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Claim.identifier:PLAC.use	required	IdentifierUse
Claim.identifier:PLAC.type	extensible	Pattern: PLAC("Placer Identifier")
Claim.identifier:INTER.use	required	IdentifierUse
Claim.identifier:INTER.type	extensible	Pattern: INTER("Intermediary System Identifier")
Claim.status	required	FinancialResourceStatusCodes
Claim.type	extensible	Pattern: professional
Claim.subType	example	ExampleClaimSubTypeCodes
Claim.use	required	Pattern: predetermination
Claim.provider.type	extensible	ResourceType
Claim.priority	required	ProcessPriorityCodes
Claim.fundsReserve	example	Funds Reservation Codes
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes
Claim.payee.type	example	Claim Payee Type Codes
Claim.referral.type	extensible	ResourceType
Claim.careTeam.role	required	PCTCareTeamRoleVS
Claim.careTeam.qualification	required	USCoreProviderRoleNucc
Claim.careTeam:rendering.role	example	Pattern: rendering
Claim.careTeam:rendering.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:referring.role	example	Pattern: referring
Claim.careTeam:referring.qualification	example	ExampleProviderQualificationCodes
Claim.supportingInfo.category	extensible	PCTSupportingInfoTypeVS (a valid code from PCT GFE Supporting Info Type Code System)
Claim.supportingInfo.code	example	ExceptionCodes
Claim.supportingInfo.reason	example	MissingToothReasonCodes
Claim.supportingInfo:serviceFacility.category	example	Pattern: servicefacility
Claim.supportingInfo:serviceFacility.code	example	ExceptionCodes
Claim.supportingInfo:serviceFacility.reason	example	MissingToothReasonCodes
Claim.supportingInfo:claimFrequency.category	example	Pattern: claimFrequency
Claim.supportingInfo:claimFrequency.code	required	PCTGFEFrequencyVS (a valid code from PCT GFE Frequency Code System)
Claim.supportingInfo:claimFrequency.reason	example	MissingToothReasonCodes
Claim.diagnosis.diagnosis[x]	example	ICD-10Codes
Claim.diagnosis.type	required	PCTDiagnosisTypeVS
Claim.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.diagnosis:principal.diagnosis[x]	required	PCTDiagnosticCodes
Claim.diagnosis:principal.type	example	Pattern: principal
Claim.diagnosis:principal.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis:principal.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.diagnosis:other.diagnosis[x]	required	PCTDiagnosticCodes
Claim.diagnosis:other.type	example	Pattern: other
Claim.diagnosis:other.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis:other.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type	required	PCTProcedureTypeVS
Claim.procedure.procedure[x]	example	ICD-10ProcedureCodes
Claim.procedure:anesthesiaRelated.type	example	Pattern: procedureRequiringAnesthesia
Claim.procedure:anesthesiaRelated.procedure[x]	required	PCTProcedureSurgicalCodes
Claim.procedure:other.type	example	ExampleProcedureTypeCodes
Claim.procedure:other.procedure[x]	example	ICD-10ProcedureCodes
Claim.accident.type	extensible	ActIncidentCode
Claim.accident.location[x].use	required	AddressUse
Claim.accident.location[x].type	required	AddressType
Claim.accident.location[x].country	required	Iso3166-1-2
Claim.item.revenue	example	ExampleRevenueCenterCodes
Claim.item.category	example	BenefitCategoryCodes
Claim.item.productOrService	required	USClaimMedicalProductOrServiceCodes
Claim.item.modifier	required	PCTGFEItemCptHcpcsVS
Claim.item.programCode	example	ExampleProgramReasonCodes
Claim.item.location[x]	required	PCTGFECMSPOS
Claim.item.bodySite	example	OralSiteCodes
Claim.item.subSite	example	SurfaceCodes
Claim.item.detail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.category	example	BenefitCategoryCodes
Claim.item.detail.productOrService	required	USClaimMedicalProductOrServiceCodes
Claim.item.detail.modifier	example	ModifierTypeCodes
Claim.item.detail.programCode	example	ExampleProgramReasonCodes
Claim.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.subDetail.category	example	BenefitCategoryCodes
Claim.item.detail.subDetail.productOrService	example	USCLSCodes
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes