description: 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.
package_name: hl7.fhir.us.davinci
derivation: constraint
name: PCTAdvancedEOB
type: ExplanationOfBenefit
elements:
  extension:
    array: true
    min: 3
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: 3
      slices:
        gfeReference:
          match: {url: null}
          schema: {type: Extension, short: The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference', index: 1}
          min: 1
        disclaimer:
          match: {url: null}
          schema: {type: Extension, short: One or more disclaimers made by the payer concerning the estimated costs provided in the AEOB, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer', index: 2}
          min: 1
        expirationDate:
          match: {url: null}
          schema: {type: Extension, short: Once the AEOB is complete and formally issued it is good until this date., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate', index: 3}
          min: 1
          max: 1
  patient:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-patient']
    index: 4
  insurer:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 5
  provider:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 6
    extensions:
      outOfNetworkProviderInfo: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo', min: 0, max: 1, type: Extension, mustSupport: true, index: 7}
    elements:
      extension:
        type: Extension
        mustSupport: true
        url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo
        index: 7
        slicing:
          slices:
            outOfNetworkProviderInfo:
              match: {}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/outOfNetworkProviderInfo', index: 7}
              min: 0
              max: 1
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    mustSupport: true
    index: 8
  insurance:
    elements:
      coverage:
        type: Reference
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage']
        index: 9
  item:
    mustSupport: true
    index: 10
    extensions:
      estimatedDateOfService: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService', min: 1, max: 1, type: Extension, mustSupport: true, index: 12}
    elements:
      extension:
        index: 11
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: 1
          slices:
            estimatedDateOfService:
              match: {url: null}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService', index: 12}
              min: 1
              max: 1
      revenue:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS'}
        mustSupport: true
        index: 13
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        index: 14
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        mustSupport: true
        array: true
        max: 4
        index: 15
      quantity: {mustSupport: true, index: 16}
      net: {mustSupport: true, index: 17}
      adjudication:
        mustSupport: true
        index: 18
        extensions:
          subjectToMedicalMgmt: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', min: 0, type: Extension, mustSupport: true, index: 20}
        elements:
          extension:
            index: 19
            slicing:
              rules: open
              ordered: false
              discriminator:
              - {path: url, type: value}
              min: null
              slices:
                subjectToMedicalMgmt:
                  match: {url: null}
                  schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', index: 20}
                  min: 0
          category:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemAdjudicationVS'}
            index: 21
    required: [adjudication, net, extension]
  total: {mustSupport: true, index: 22}
package_version: pct-0.1.0
extensions:
  gfeReference: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference', min: 1, type: Extension, short: The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB., mustSupport: true, index: 1}
  disclaimer: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/disclaimer', min: 1, type: Extension, short: One or more disclaimers made by the payer concerning the estimated costs provided in the AEOB, mustSupport: true, index: 2}
  expirationDate: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/expirationDate', min: 1, max: 1, type: Extension, short: Once the AEOB is complete and formally issued it is good until this date., mustSupport: true, index: 3}
class: profile
kind: resource
url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob
base: http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
version: 0.1.0
required: [total, item]