| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Claim
|
Claim | |||
Slices for extension
|
1.. | Slice: Unordered, Open by value:url | ||
gfeSubmitter
|
1..1 | Reference () |
The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter |
|
|
gfeServiceLinkingInfo
|
S | 0..1 | (Complex) |
GFE Service Linking Information URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo |
|
providerEventMethodology
|
S | 0..1 | string |
Provider event collection methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
|
gfeDisclaimer
|
S | 0..* | string |
Disclaimers the patient should be made aware of regarding the providers estimate URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer |
Slices for identifier
|
1 .. | Slice: Unordered, Open by pattern:type | ||
identifier:PLAC
|
1..1 | Provider Assigned Identifier for GFE Claim | ||
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://terminology.hl7.org/CodeSystem/v2-0203 |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: PLAC |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Placer Identifier |
|
|
system
|
S | |||
value
|
1.. | |||
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 |
|
|
type
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: professional |
|
|
use
|
Required Pattern: predetermination | |||
patient
|
Reference (HRex Patient Demographics) | |||
|
insurer
|
1.. | Reference (PCT Organization) | ||
|
provider
|
Reference (PCT Organization | PCT Practitioner) | Billing provider - party responsible for the GFE | ||
|
extension
|
1.. | |||
|
providerTaxonomy
|
1..1 | CodeableConcept |
Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy Binding: todo ( extensible ) |
|
|
consentForBalanceBilling
|
S | 0..1 | boolean |
Extension
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling |
|
priority
|
Binding: Process Priority Codes ( required ) | |||
|
payee
|
S | |||
|
party
|
Reference (PCT Practitioner | PCT Organization) | |||
|
referral
|
||||
|
extension
|
1.. | |||
|
referralNumber
|
1..1 | string |
Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber |
|
|
Slices for careTeam
|
S | Slice: Unordered, Open by pattern:role | ||
|
careTeam:All Slices
|
Content/Rules for all slices | |||
|
provider
|
Reference (PCT Practitioner | PCT Organization) | |||
|
role
|
1.. | Binding: PCT Care Team Role Value Set ( required ) | ||
|
qualification
|
Binding: todo ( required ) | |||
|
careTeam:rendering
|
0..* | |||
|
role
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: rendering |
|
|
qualification
|
1.. | Practitioner credential or specialization - must provide a taxonomy code for the Professional case | ||
|
careTeam:referring
|
0..1 | |||
|
role
|
Required Pattern: At least the following | |||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: referring |
|
|
Slices for supportingInfo
|
S | Slice: Unordered, Open by pattern:category | ||
|
supportingInfo:All Slices
|
Content/Rules for all slices | |||
|
category
|
Binding: PCT Supporting Info Type Value Set ( extensible ) | |||
|
supportingInfo:serviceFacility
|
S | 0..1 | Service Facility | |
|
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/PCTSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: servicefacility |
|
|
value[x]
|
1 .. | Slice: Unordered, Open by type:$this | ||
|
valueReference
|
1..1 | Reference (PCT Organization) | ||
|
supportingInfo:claimFrequency
|
S | 0..1 | Claim Frequency | |
|
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/PCTSupportingInfoType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: claimFrequency |
|
|
code
|
1.. | Binding: PCT GFE Frequency Code Value Set ( required ) | ||
|
Slices for diagnosis
|
S | 1 .. | Slice: Unordered, Open by pattern:type | |
|
diagnosis:All Slices
|
Content/Rules for all slices | |||
|
type
|
S | Binding: PCT Diagnosis Type Value Set ( required ) | ||
|
diagnosis:principal
|
1..1 | |||
|
sequence
|
Required Pattern: 1 | |||
diagnosis[x]
|
CodeableConcept | Binding: PCT ICD-10 Diagnostic Codes ( required ) | ||
|
type
|
1..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://terminology.hl7.org/CodeSystem/ex-diagnosistype |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: principal |
|
|
diagnosis:other
|
S | 0..11 | ||
|
diagnosis[x]
|
CodeableConcept | Binding: PCT ICD-10 Diagnostic Codes ( required ) | ||
|
type
|
1..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/PCTDiagnosisType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: other |
|
|
Slices for procedure
|
S | Slice: Unordered, Open by pattern:type | ||
|
procedure:All Slices
|
Content/Rules for all slices | |||
|
Slices for extension
|
1.. | Slice: Unordered, Open by value:url | ||
|
serviceDescription
|
1..1 | string |
Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
|
|
type
|
S | Binding: PCT Procedure Type Value Set ( required ) | ||
|
procedure:anesthesiaRelated
|
S | 0..2 | ||
|
serviceDescription
|
1..1 | string |
Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
|
|
type
|
1..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/PCTProcedureType |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: procedureRequiringAnesthesia |
|
|
procedure[x]
|
CodeableConcept | Binding: PCT CMS HCPCS and AMA CPT Procedure Surgical Codes ( required ) | ||
|
procedure:other
|
S | 0..24 | ||
|
insurance
|
||||
|
coverage
|
Reference (PCT Coverage) | |||
|
preAuthRef
|
..2 | |||
|
accident
|
||||
|
location[x]
|
Address | |||
|
country
|
Binding: Iso 3166 Part 1: 2 Letter Codes ( required ) | |||
|
item
|
1..50 | |||
|
Slices for extension
|
1.. | Slice: Unordered, Open by value:url | ||
|
referralNumber
|
S | 0..11 | string |
Referral Number URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber |
|
gfeBillingProviderLineItemCtrlNum
|
S | 0..1 | Identifier |
Extension
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum |
|
serviceDescription
|
1..1 | string |
Service Description
URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription |
|
|
ProviderEventMethodology
|
S | 0..1 | string |
Provider Event Methodology URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology |
|
careTeamSequence
|
S | |||
|
productOrService
|
Binding: Claim Medical Product or Service Value Set ( required ) | |||
|
modifier
|
S | ..4 | Binding: PCT GFE Item CPT - HCPCS Value Set ( required ) | |
|
serviced[x]
|
S | 1.. | This is the planned or estimated date(s)s of service | |
|
location[x]
|
1 .. | CodeableConcept | Slice: Unordered, Open by type:$this | |
|
locationCodeableConcept
|
1..1 | Binding: PCT GFE CMS Place of Service Value Set ( required ) | ||
|
quantity
|
1.. | |||
|
unitPrice
|
1.. | |||
|
net
|
1.. | Total charge amount for the service line | ||
|
detail
|
S | Drug Identification Information | ||
|
productOrService
|
Binding: Claim Medical Product or Service Value Set ( required ) | |||
|
quantity
|
S | |||
|
total
|
1.. | Total GFE Charges Submitted | ||
|
Documentation for this format
|
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