Patient Cost Transparency Implementation Guide
1.1.0 - STU 1 United States of America flag

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v1.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: PCT Advanced EOB

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob Version: 1.1.0
Standards status: Trial-use Computable Name: PCTAdvancedEOB

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).
  • .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 (paidtoprovider) or the subscriber (paidtopatient)
  • 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.

    • 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.

Usage:

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... type 1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... type 1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
... type 1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: predetermination
... patient 1..1Reference(HRex Patient Demographics)The recipient of the products and services
... created 1..1dateTimeThe date and time this estimate was calculated.
... insurer 1..1Reference(PCT Organization)Party responsible for reimbursement
... provider 1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1Reference(Claim)Claim reference
.... identifier 1..1IdentifierGFE identifier of the originally submitted claim
..... system S0..1uriThe namespace for the identifier value
..... value 1..1stringThe value that is unique
... insurance
.... coverage 1..1Reference(PCT Coverage)Insurance information
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1date, PeriodThis is the planned or estimated date(s)s of service
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
...... amount 0..0
...... value 0..0
..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S0..1BackboneElementMember liability
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S0..1BackboneElementEligible amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
..... amount 0..0
..... value 0..0
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S0..1BackboneElementMember liability
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S0..1BackboneElementEligible amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt S, Money SBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt S
...... allowedMoneyMoney S
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt S
...... usedMoneyMoney S

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... outOfNetworkProviderInfo S0..1urlIn Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: predetermination
... patient Σ1..1Reference(HRex Patient Demographics)The recipient of the products and services
... created Σ1..1dateTimeThe date and time this estimate was calculated.
... insurer Σ1..1Reference(PCT Organization)Party responsible for reimbursement
... provider Σ1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1Reference(Claim)Claim reference
.... identifier Σ1..1IdentifierGFE identifier of the originally submitted claim
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... system SΣ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(PCT Coverage)Insurance information
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1This is the planned or estimated date(s)s of service
..... servicedDatedate
..... servicedPeriodPeriod
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S0..1BackboneElementMember liability
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S0..1BackboneElementEligible amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S0..1BackboneElementMember liability
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S0..1BackboneElementEligible amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for total Σ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt, MoneyBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedMoneyMoney
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc("Unique Claim ID")
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.userequiredPattern: predetermination
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.claim.identifier.userequiredIdentifierUse
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.item.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.item.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.item.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.item.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... outOfNetworkProviderInfo S0..1urlIn Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: predetermination
... patient Σ1..1Reference(HRex Patient Demographics)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeThe date and time this estimate was calculated.
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ1..1Reference(PCT Organization)Party responsible for reimbursement
... provider Σ1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 1..1Reference(Claim)Claim reference
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ1..1IdentifierGFE identifier of the originally submitted claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system SΣ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... display Σ0..1stringText alternative for the resource
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(PCT Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 1..1This is the planned or estimated date(s)s of service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:memberliability S0..1BackboneElementMember liability
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:eligible S0..1BackboneElementEligible amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:memberliability S0..1BackboneElementMember liability
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:eligible S0..1BackboneElementEligible amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... Slices for total Σ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt S, Money SBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt S
...... allowedMoneyMoney S
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt S
...... usedMoneyMoney S

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc("Unique Claim ID")
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
ExplanationOfBenefit.userequiredPattern: predetermination
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
ExplanationOfBenefit.claim.typeextensibleResourceType
ExplanationOfBenefit.claim.identifier.userequiredIdentifierUse
ExplanationOfBenefit.claim.identifier.typeextensibleIdentifier Type Codes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.item.adjudication:medicalmanagement.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.item.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.item.adjudication:submitted.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.item.adjudication:memberliability.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.item.adjudication:eligible.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.item.adjudication:benefit.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.adjudication:medicalmanagement.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.adjudication:submitted.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.adjudication:memberliability.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.adjudication:eligible.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.adjudication:benefit.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 21 elements (5 nested mandatory elements)
Must-Support: 30 elements
Prohibited: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.identifier is sliced based on the value of pattern:type
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

Differential View

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... type 1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... type 1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
... type 1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: predetermination
... patient 1..1Reference(HRex Patient Demographics)The recipient of the products and services
... created 1..1dateTimeThe date and time this estimate was calculated.
... insurer 1..1Reference(PCT Organization)Party responsible for reimbursement
... provider 1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1Reference(Claim)Claim reference
.... identifier 1..1IdentifierGFE identifier of the originally submitted claim
..... system S0..1uriThe namespace for the identifier value
..... value 1..1stringThe value that is unique
... insurance
.... coverage 1..1Reference(PCT Coverage)Insurance information
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1date, PeriodThis is the planned or estimated date(s)s of service
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
...... amount 0..0
...... value 0..0
..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S0..1BackboneElementMember liability
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S0..1BackboneElementEligible amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
..... amount 0..0
..... value 0..0
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S0..1BackboneElementMember liability
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S0..1BackboneElementEligible amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt S, Money SBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt S
...... allowedMoneyMoney S
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt S
...... usedMoneyMoney S

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... outOfNetworkProviderInfo S0..1urlIn Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: predetermination
... patient Σ1..1Reference(HRex Patient Demographics)The recipient of the products and services
... created Σ1..1dateTimeThe date and time this estimate was calculated.
... insurer Σ1..1Reference(PCT Organization)Party responsible for reimbursement
... provider Σ1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... claim 1..1Reference(Claim)Claim reference
.... identifier Σ1..1IdentifierGFE identifier of the originally submitted claim
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... system SΣ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(PCT Coverage)Insurance information
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... serviced[x] 1..1This is the planned or estimated date(s)s of service
..... servicedDatedate
..... servicedPeriodPeriod
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
..... adjudication:memberliability S0..1BackboneElementMember liability
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
..... adjudication:eligible S0..1BackboneElementEligible amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
.... adjudication:memberliability S0..1BackboneElementMember liability
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
.... adjudication:eligible S0..1BackboneElementEligible amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
... Slices for total Σ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt, MoneyBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedMoneyMoney
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc("Unique Claim ID")
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.userequiredPattern: predetermination
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.claim.identifier.userequiredIdentifierUse
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.item.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.item.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.item.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.item.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... 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
... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
... outOfNetworkProviderInfo S0..1urlIn Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:INTER 0..*IdentifierIntermediary System Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: INTER
....... display1..1stringRepresentation defined by the system
Fixed Value: Intermediary System Identifier
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:uniqueclaimid 1..1IdentifierUnique Claim ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display1..1stringRepresentation defined by the system
Fixed Value: Unique Claim ID
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: PCT Advance Explanation of Benefit Type Value Set (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: predetermination
... patient Σ1..1Reference(HRex Patient Demographics)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeThe date and time this estimate was calculated.
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ1..1Reference(PCT Organization)Party responsible for reimbursement
... provider Σ1..1Reference(PCT Practitioner | PCT Organization)Party responsible for the claim
... priority S0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 1..1Reference(Claim)Claim reference
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ1..1IdentifierGFE identifier of the originally submitted claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system SΣ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... display Σ0..1stringText alternative for the resource
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(PCT Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... serviceDescription SC0..1stringService Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: PCT GFE NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Claim Medical Product or Service Value Set (required)
.... modifier S0..4CodeableConceptProduct or service billing modifiers
Binding: PCT GFE Item CPT - HCPCS Value Set (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 1..1This is the planned or estimated date(s)s of service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:medicalmanagement S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
...... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:submitted S0..1BackboneElementProvider submitted amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:memberliability S0..1BackboneElementMember liability
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:eligible S0..1BackboneElementEligible amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:benefit S0..1BackboneElementBenefit amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: PCT GFE Item Adjudication Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:medicalmanagement S0..*BackboneElementHeader-level adjudication
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... subjectToMedicalMgmt 1..1CodeableConceptSubject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt
Binding: PCT Subject-To-Medical-Management Reason Value Set (extensible)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalmanagement
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

.... adjudication:billingnetworkstatus S0..1BackboneElementBilling Provider Network Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:renderingnetworkstatus S0..1BackboneElementRendering Provider Network Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefitpaymentstatus S0..1BackboneElementBenefit Payment Status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Payer Benefit Payment Status (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjustmentreason S0..*BackboneElementAdjustment Reason
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: PCT Adjustment Reason (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:submitted S0..1BackboneElementProvider submitted amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:memberliability S0..1BackboneElementMember liability
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: memberliability
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:eligible S0..1BackboneElementEligible amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: eligible
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefit S0..1BackboneElementBenefit amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefit
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... Slices for total Σ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: PCT Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 1..*BackboneElementDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... processNoteClass 0..1CodeableConceptProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass
Binding: PCT AEOB Process Note Types (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 1..1PeriodWhen the benefits are applicable
... benefitBalance 1..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: PCT benefitBalance.category codes (required)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 1..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (required)
.... term 1..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (required)
.... financial 1..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... remaining S0..1unsignedInt S, Money SBenefit Remaining
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: PCT Financial Type Value Set (required)
..... allowed[x] S1..1Benefits allowed
...... allowedUnsignedIntunsignedInt S
...... allowedMoneyMoney S
..... used[x] S1..1Benefits used
...... usedUnsignedIntunsignedInt S
...... usedMoneyMoney S

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:INTER.userequiredIdentifierUse
ExplanationOfBenefit.identifier:INTER.typeextensiblePattern: INTER("Intermediary System Identifier")
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc("Unique Claim ID")
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPCTAEOBTypeVS
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
ExplanationOfBenefit.userequiredPattern: predetermination
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
ExplanationOfBenefit.claim.typeextensibleResourceType
ExplanationOfBenefit.claim.identifier.userequiredIdentifierUse
ExplanationOfBenefit.claim.identifier.typeextensibleIdentifier Type Codes
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenuerequiredPCTGFEItemRevenueVS
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredUSClaimMedicalProductOrServiceCodes
ExplanationOfBenefit.item.modifierrequiredPCTGFEItemCptHcpcsVS
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.item.adjudication:medicalmanagement.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.item.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.item.adjudication:submitted.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.item.adjudication:memberliability.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.item.adjudication:eligible.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.item.adjudication:benefit.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryextensiblePCTAdjudicationCategoryVS
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:medicalmanagement.categoryexamplePattern: medicalmanagement
ExplanationOfBenefit.adjudication:medicalmanagement.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredPCTPayerBenefitPaymentStatusVS
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredPCTAdjustmentReasonVS
ExplanationOfBenefit.adjudication:submitted.categoryexamplePattern: submitted
ExplanationOfBenefit.adjudication:submitted.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:memberliability.categoryexamplePattern: memberliability
ExplanationOfBenefit.adjudication:memberliability.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:eligible.categoryexamplePattern: eligible
ExplanationOfBenefit.adjudication:eligible.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:benefit.categoryexamplePattern: benefit
ExplanationOfBenefit.adjudication:benefit.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.total.categoryextensiblePCTAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredPCTAdjudication
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryrequiredPCTBenefitBalanceCategoryVS
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitrequiredUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termrequiredBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typerequiredPCTFinancialTypeVS (a valid code from PCT Financial Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
pct-aeob-1errorExplanationOfBenefitInstitutional 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-2errorExplanationOfBenefitInstitutional 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-3errorExplanationOfBenefitInstitutional 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()

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 21 elements (5 nested mandatory elements)
Must-Support: 30 elements
Prohibited: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.identifier is sliced based on the value of pattern:type
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

 

Other representations of profile: CSV, Excel, Schematron