description: This profile is used for exchanging a summary of Explanation of Benefit (EoB) information, including costs and benefits, of all of the Advanced EoB data contained within an Advance EoB Bundle.
package_name: hl7.fhir.us.davinci-pct.r4b
derivation: constraint
name: PCTAdvancedEOBSummary
type: ExplanationOfBenefit
elements:
  patient:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics']
    index: 9
  insurance:
    elements:
      coverage:
        type: Reference
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage']
        index: 35
  benefitBalance:
    index: 62
    elements:
      category:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS'}
        index: 63
      unit:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        index: 64
      term:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        index: 65
      financial:
        index: 66
        elements:
          type:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS'}
            index: 67
          allowed:
            choices: []
            index: 69
            slicing:
              rules: open
              ordered: false
              discriminator:
              - {path: $this, type: type}
              min: 1
              slices:
                allowedMoney:
                  match: {}
                  schema:
                    choices: [allowedMoney]
                    _required: true
                    index: 71
                  min: 1
                  max: 1
          allowedMoney:
            type: Money
            choiceOf: allowed
            index: 72
            slicing:
              slices:
                allowedMoney:
                  match: {}
                  schema: {type: Money, choiceOf: allowed, _required: true, index: 72}
                  min: 1
                  max: 1
          used:
            choices: []
            index: 74
            slicing:
              rules: open
              ordered: false
              discriminator:
              - {path: $this, type: type}
              min: 1
              slices:
                usedMoney:
                  match: {}
                  schema:
                    choices: [usedMoney]
                    _required: true
                    index: 76
                  min: 1
                  max: 1
          usedMoney:
            type: Money
            choiceOf: used
            index: 77
            slicing:
              slices:
                usedMoney:
                  match: {}
                  schema: {type: Money, choiceOf: used, _required: true, index: 77}
                  min: 1
                  max: 1
        required: [allowedMoney, usedMoney, used, allowed]
    required: [term, financial, unit]
  facility: {index: 29}
  processNote:
    short: Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible. This may include a note about out of network providers or prior authorization.
    index: 58
    extensions:
      processNoteClass: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass', min: 0, max: 1, type: Extension, index: 60}
    elements:
      extension:
        index: 59
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            processNoteClass:
              match: {url: null}
              schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass', index: 60}
              min: 0
              max: 1
  preAuthRef: {index: 31}
  adjudication: {index: 38}
  enterer: {index: 12}
  supportingInfo: {index: 33}
  use:
    pattern: {type: Code, value: predetermination}
    index: 8
  payment: {index: 57}
  item: {index: 36}
  type:
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: estimate-summary, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse'}
    index: 6
  created: {short: The date and time this summary was generated., index: 11}
  extension:
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: null
      slices:
        serviceDescription:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 1}
          min: 0
          max: 1
        outOfNetworkProviderInfo:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink', index: 2}
          min: 0
          max: 1
  referral: {index: 28}
  preAuthRefPeriod: {index: 32}
  total:
    index: 39
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal'}
        mustSupport: true
        index: 40
    slicing:
      rules: open
      ordered: false
      description: Slice based on value pattern
      discriminator:
      - {path: category, type: pattern}
      min: 1
      slices:
        submitted:
          match:
            category:
              coding:
              - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Total provider submitted amount
            mustSupport: true
            _required: true
            index: 41
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 42
        memberliability:
          match:
            category:
              coding:
              - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            short: Total member liability - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 43
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 44
        innetwork:
          match:
            category:
              coding:
              - {code: innetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total in network amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 45
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: innetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 46
        outofnetwork:
          match:
            category:
              coding:
              - {code: outofnetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total out of network amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 47
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: outofnetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 48
        noncovered:
          match:
            category:
              coding:
              - {code: noncovered, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication'}
          schema:
            short: Total noncovered amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 49
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: noncovered, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication'}
                index: 50
        negotiated:
          match:
            category:
              coding:
              - {code: negotiated, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total negotiated amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 51
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: negotiated, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 52
        eligible:
          match:
            category:
              coding:
              - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Total eligible amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 53
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 54
        benefit:
          match:
            category:
              coding:
              - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Total benefit amount - Must include in non-zero total across all AEoBs
            mustSupport: true
            index: 55
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 56
  insurer:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 13
  fundsReserve: {index: 24}
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    index: 22
  payee: {index: 27}
  prescription: {index: 25}
  billablePeriod: {short: The full Period of Care for all services or products included in the estimate from the first event to the last event., index: 10}
  identifier:
    index: 3
    slicing:
      rules: open
      description: Slice based on type pattern
      discriminator:
      - {path: type, type: pattern}
      min: null
      slices:
        INTER:
          match:
            type:
              coding:
              - {code: INTER, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Intermediary System Identifier}
          schema:
            short: Intermediary System Identifier
            array: true
            index: 4
            elements:
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: INTER, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Intermediary System Identifier}
                index: 5
            required: [type]
  subType: {index: 7}
  fundsReserveRequested: {index: 23}
  benefitPeriod: {index: 61}
  precedence: {index: 34}
  provider:
    extensions:
      dataAbsentReason:
        url: http://hl7.org/fhir/StructureDefinition/data-absent-reason
        type: Extension
        index: 15
        elements:
          value:
            pattern: {type: Code, value: not-applicable}
            choices: []
            index: 17
    elements:
      extension:
        index: 14
        slicing:
          slices:
            dataAbsentReason:
              match: {}
              schema:
                type: Extension
                url: http://hl7.org/fhir/StructureDefinition/data-absent-reason
                index: 15
                elements:
                  value:
                    pattern: {type: Code, value: not-applicable}
                    choices: []
                    index: 17
      reference: {index: 18}
      type: {index: 19}
      identifier: {index: 20}
      display: {index: 21}
    required: [extension]
  addItem: {index: 37}
  originalPrescription: {index: 26}
  claim: {index: 30}
package_version: 2.0.0-ballot
extensions:
  serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 0, max: 1, type: Extension, mustSupport: true, index: 1}
  outOfNetworkProviderInfo: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink', min: 0, max: 1, type: Extension, mustSupport: true, index: 2}
class: profile
kind: resource
url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-summary
base: http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
version: 2.0.0-ballot
required: [total, benefitPeriod, billablePeriod, processNote, benefitBalance]