| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ExplanationOfBenefit
|
C | ExplanationOfBenefit |
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.. | 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
|
S C | 0..1 | string |
Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
|
outOfNetworkProviderInfo
|
S | 0..1 | url |
In Network Provider Options Link
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink |
Slices for identifier
|
1 .. | Slice: Unordered, Open by pattern:type | ||
identifier:INTER
|
0..* |
Intermediary System Identifier |
||
type
|
1.. | Required Pattern: At least the following | ||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: INTER |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Intermediary System Identifier |
|
identifier:uniqueclaimid
|
1..1 | Unique Claim ID | ||
|
type
|
1.. | Required Pattern: At least the following | ||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: uc |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Unique Claim ID |
|
|
type
|
Binding: PCT Advance Explanation of Benefit Type Value Set ( required ) | |||
|
use
|
Required Pattern: predetermination | |||
patient
|
Reference (HRex Patient Demographics) | |||
|
created
|
The date and time this estimate was calculated. | |||
|
insurer
|
Reference (PCT Organization) | |||
|
provider
|
Reference (PCT Practitioner | PCT Organization) | |||
|
priority
|
S | Binding: Process Priority Codes ( required ) | ||
|
claim
|
1.. | |||
|
identifier
|
1.. | GFE identifier of the originally submitted claim | ||
|
system
|
S | |||
|
value
|
1.. | |||
|
insurance
|
||||
|
coverage
|
Reference (PCT Coverage) | |||
|
item
|
1.. | |||
|
Slices for extension
|
Slice: Unordered, Open by value:url | |||
|
serviceDescription
|
S C | 0..1 | string |
Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) |
|
revenue
|
Binding: PCT GFE NUBC Revenue Value Set ( required ) | |||
|
productOrService
|
Binding: Claim Medical Product or Service Value Set ( required ) | |||
|
modifier
|
S | ..4 | Binding: PCT GFE Item CPT - HCPCS Value Set ( required ) | |
|
serviced[x]
|
1.. | This is the planned or estimated date(s)s of service | ||
|
quantity
|
S | |||
|
Slices for adjudication
|
S | 1 .. | Slice: Unordered, Open by pattern:category | |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
Binding: PCT GFE Item Adjudication Value Set ( extensible ) | |||
|
adjudication:medicalmanagement
|
S | 0..* | ||
Slices for extension
|
1.. | Slice: Unordered, Open by value:url | ||
|
subjectToMedicalMgmt
|
1..1 | CodeableConcept |
Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set ( extensible ) |
|
|
category
|
Required Pattern: At least the following | |||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: medicalmanagement |
|
|
amount
|
.. 0 | |||
|
value
|
.. 0 | |||
|
adjudication:benefitpaymentstatus
|
S | 0..1 | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus |
|
|
reason
|
Binding: PCT Payer Benefit Payment Status ( required ) | |||
|
adjudication:adjustmentreason
|
S | 0..* |
Adjustment Reason |
|
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: adjustmentreason |
|
|
reason
|
Binding: PCT Payer Benefit Payment Status ( required ) | |||
|
adjudication:submitted
|
S | 0..1 | Provider submitted amount | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: submitted |
|
|
adjudication:memberliability
|
S | 0..1 | Member liability | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: memberliability |
|
|
adjudication:eligible
|
S | 0..1 | Eligible amount | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: eligible |
|
|
adjudication:benefit
|
S | 0..1 | Benefit amount | |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: benefit |
|
|
Slices for adjudication
|
S | BackboneElement | Slice: Unordered, Open by pattern:category | |
|
adjudication:All Slices
|
Content/Rules for all slices | |||
|
category
|
Binding: PCT GFE Item Adjudication Value Set ( extensible ) | |||
|
adjudication:medicalmanagement
|
S | 0..* | BackboneElement | |
|
Slices for extension
|
1.. | Slice: Unordered, Open by value:url | ||
|
subjectToMedicalMgmt
|
1..1 | CodeableConcept |
Subject To Medical Management
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: PCT Subject-To-Medical-Management Reason Value Set ( extensible ) |
|
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: medicalmanagement |
|
|
amount
|
.. 0 | |||
|
value
|
.. 0 | |||
|
adjudication:billingnetworkstatus
|
S | 0..1 | BackboneElement | Billing Provider Network Status |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: billingnetworkstatus |
|
|
reason
|
Binding: PCT GFE Item Adjudication Value Set ( required ) | |||
|
adjudication:renderingnetworkstatus
|
S | 0..1 | BackboneElement | Rendering Provider Network Status |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus |
|
|
reason
|
Binding: PCT GFE Item Adjudication Value Set ( required ) | |||
|
adjudication:benefitpaymentstatus
|
S | 0..1 | BackboneElement | Benefit Payment Status |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus |
|
|
reason
|
Binding: PCT GFE Item Adjudication Value Set ( required ) | |||
|
adjudication:adjustmentreason
|
S | 0..* | BackboneElement |
Adjustment Reason |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: adjustmentreason |
|
|
reason
|
Binding: PCT GFE Item Adjudication Value Set ( required ) | |||
|
adjudication:submitted
|
S | 0..1 | BackboneElement | Provider submitted amount |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: submitted |
|
|
adjudication:memberliability
|
S | 0..1 | BackboneElement | Member liability |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: memberliability |
|
|
adjudication:eligible
|
S | 0..1 | BackboneElement | Eligible amount |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: eligible |
|
|
adjudication:benefit
|
S | 0..1 | BackboneElement | Benefit amount |
|
category
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: benefit |
|
|
Slices for total
|
1 .. | Slice: Unordered, Open by pattern:category | ||
|
total:All Slices
|
Content/Rules for all slices | |||
|
category
|
S | Binding: PCT Adjudication Value Set ( extensible ) | ||
|
total:adjudicationamounttype
|
S | 1..* |
Total adjudication type and amount |
|
|
category
|
Binding: PCT Adjudication Value Set ( required ) | |||
|
processNote
|
1.. | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible | ||
|
Slices for extension
|
Slice: Unordered, Open by value:url | |||
|
processNoteClass
|
0..1 | CodeableConcept |
ProcessNote Class
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types ( required ) |
|
|
benefitPeriod
|
1.. | |||
|
benefitBalance
|
1.. | |||
|
category
|
Binding: PCT benefitBalance.category codes ( required ) | |||
|
unit
|
1.. | Binding: Unit Type Codes ( required ) | ||
|
term
|
1.. | Binding: Benefit Term Codes ( required ) | ||
|
financial
|
1.. | |||
|
type
|
Binding: PCT Financial Type Value Set ( required ) | |||
|
allowed[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
allowedMoney
|
1..1 | Money | ||
|
used[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
|
usedMoney
|
1..1 | Money | ||
|
Documentation for this format
|
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