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:
  patient:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics']
    index: 11
  insurance:
    elements:
      coverage:
        type: Reference
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage']
        index: 20
  benefitBalance:
    index: 88
    elements:
      category:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS'}
        index: 89
      unit:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        index: 90
      term:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        index: 91
      financial:
        index: 92
        elements:
          type:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS'}
            index: 93
          allowed:
            choices: []
            index: 95
          allowedMoney: {type: Money, index: 96}
          used:
            choices: []
            index: 98
          usedMoney: {type: Money, index: 99}
        required: [allowedMoney, usedMoney, used, allowed]
    required: [term, financial, unit]
  processNote:
    short: Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible
    index: 84
    extensions:
      processNoteClass: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass', min: 0, max: 1, type: Extension, index: 86}
    elements:
      extension:
        index: 85
        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: 86}
              min: 0
              max: 1
  adjudication:
    type: BackboneElement
    mustSupport: true
    index: 52
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
        index: 53
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: category, type: pattern}
      min: null
      slices:
        eligible:
          match:
            category:
              coding:
              - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Eligible amount
            type: BackboneElement
            mustSupport: true
            index: 76
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 77
        adjustmentreason:
          match:
            category:
              coding:
              - {code: adjustmentreason, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            type: BackboneElement
            short: Adjustment Reason
            mustSupport: true
            array: true
            index: 69
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: adjustmentreason, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 70
              reason:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
                index: 71
        submitted:
          match:
            category:
              coding:
              - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            type: BackboneElement
            short: Provider submitted amount
            mustSupport: true
            index: 72
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 73
        medicalmanagement:
          match:
            category:
              coding:
              - {code: medicalmanagement, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            type: BackboneElement
            mustSupport: true
            array: true
            index: 54
            extensions:
              subjectToMedicalMgmt: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', min: 1, max: 1, type: Extension, index: 56}
            elements:
              extension:
                index: 55
                slicing:
                  rules: open
                  ordered: false
                  discriminator:
                  - {path: url, type: value}
                  min: 1
                  slices:
                    subjectToMedicalMgmt:
                      match: {url: null}
                      schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', index: 56}
                      min: 1
                      max: 1
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: medicalmanagement, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 57
              amount: {index: 58}
              value: {index: 59}
            required: [extension]
        benefit:
          match:
            category:
              coding:
              - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Benefit amount
            type: BackboneElement
            mustSupport: true
            index: 78
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 79
        billingnetworkstatus:
          match:
            category:
              coding:
              - {code: billingnetworkstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            type: BackboneElement
            short: Billing Provider Network Status
            mustSupport: true
            index: 60
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: billingnetworkstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 61
              reason:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
                index: 62
        memberliability:
          match:
            category:
              coding:
              - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            short: Member liability
            type: BackboneElement
            mustSupport: true
            index: 74
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 75
        renderingnetworkstatus:
          match:
            category:
              coding:
              - {code: renderingnetworkstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            type: BackboneElement
            short: Rendering Provider Network Status
            mustSupport: true
            index: 63
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: renderingnetworkstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 64
              reason:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
                index: 65
        benefitpaymentstatus:
          match:
            category:
              coding:
              - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            type: BackboneElement
            short: Benefit Payment Status
            mustSupport: true
            index: 66
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 67
              reason:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
                index: 68
  use:
    pattern: {type: Code, value: predetermination}
    index: 10
  item:
    index: 21
    extensions:
      serviceDescription:
        url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
        min: 0
        max: 1
        constraint:
          pct-aeob-1: {human: 'Institutional EOB:  SHALL have serviceDescription at the item or header level (can be at both locations)', source: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob', severity: error, expression: '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()'}
        type: Extension
        mustSupport: true
        index: 23
    elements:
      extension:
        index: 22
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            serviceDescription:
              match: {url: null}
              schema:
                constraint:
                  pct-aeob-1: {human: 'Institutional EOB:  SHALL have serviceDescription at the item or header level (can be at both locations)', source: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob', severity: error, expression: '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()'}
                type: Extension
                mustSupport: true
                url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
                index: 23
              min: 0
              max: 1
      revenue:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS'}
        index: 24
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'}
        index: 25
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        mustSupport: true
        array: true
        max: 4
        index: 26
      serviced:
        short: This is the planned or estimated date(s)s of service
        choices: []
        index: 28
      quantity: {mustSupport: true, index: 29}
      adjudication:
        mustSupport: true
        index: 30
        elements:
          category:
            binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS'}
            index: 31
        slicing:
          rules: open
          ordered: false
          description: Slice based on $this pattern
          discriminator:
          - {path: category, type: pattern}
          min: 1
          slices:
            medicalmanagement:
              match:
                category:
                  coding:
                  - {code: medicalmanagement, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
              schema:
                mustSupport: true
                array: true
                index: 32
                extensions:
                  subjectToMedicalMgmt: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', min: 1, max: 1, type: Extension, index: 34}
                elements:
                  extension:
                    index: 33
                    slicing:
                      rules: open
                      ordered: false
                      discriminator:
                      - {path: url, type: value}
                      min: 1
                      slices:
                        subjectToMedicalMgmt:
                          match: {url: null}
                          schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt', index: 34}
                          min: 1
                          max: 1
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: medicalmanagement, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                    index: 35
                  amount: {index: 36}
                  value: {index: 37}
                required: [extension]
            benefitpaymentstatus:
              match:
                category:
                  coding:
                  - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
              schema:
                short: 'Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.'
                mustSupport: true
                index: 38
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: benefitpaymentstatus, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                    index: 39
                  reason:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS'}
                    index: 40
            adjustmentreason:
              match:
                category:
                  coding:
                  - {code: adjustmentreason, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
              schema:
                short: Adjustment Reason
                mustSupport: true
                array: true
                index: 41
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: adjustmentreason, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                    index: 42
                  reason:
                    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS'}
                    index: 43
            submitted:
              match:
                category:
                  coding:
                  - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
              schema:
                short: Provider submitted amount
                mustSupport: true
                index: 44
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                    index: 45
            memberliability:
              match:
                category:
                  coding:
                  - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
              schema:
                short: Member liability
                mustSupport: true
                index: 46
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                    index: 47
            eligible:
              match:
                category:
                  coding:
                  - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
              schema:
                short: Eligible amount
                mustSupport: true
                index: 48
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                    index: 49
            benefit:
              match:
                category:
                  coding:
                  - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
              schema:
                short: Benefit amount
                mustSupport: true
                index: 50
                elements:
                  category:
                    pattern:
                      type: CodeableConcept
                      value:
                        coding:
                        - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                    index: 51
    required: [adjudication, serviced]
  type:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS'}
    index: 9
  created: {short: The date and time this estimate was calculated., index: 12}
  extension:
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: 1
      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., url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference', index: 1}
          min: 1
        serviceDescription:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 2}
          min: 0
          max: 1
        outOfNetworkProviderInfo:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink', index: 3}
          min: 0
          max: 1
  total:
    index: 80
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication'}
        mustSupport: true
        index: 81
    slicing:
      rules: open
      ordered: false
      description: Slice based on value pattern
      discriminator:
      - {path: category, type: pattern}
      min: 1
      slices:
        adjudicationamounttype:
          match: {category: null}
          schema:
            short: Total adjudication type and amount
            mustSupport: true
            array: true
            min: 1
            _required: true
            index: 82
            elements:
              category:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudication'}
                index: 83
  insurer:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 13
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    mustSupport: true
    index: 15
  identifier:
    index: 4
    slicing:
      rules: open
      description: Slice based on type pattern
      discriminator:
      - {path: type, type: pattern}
      min: 1
      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: 5
            elements:
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: INTER, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Intermediary System Identifier}
                index: 6
            required: [type]
        uniqueclaimid:
          match:
            type:
              coding:
              - {code: uc, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Unique Claim ID}
          schema:
            short: Unique Claim ID
            _required: true
            index: 7
            elements:
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: uc, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Unique Claim ID}
                index: 8
            required: [type]
  benefitPeriod: {index: 87}
  provider:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization', 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner']
    index: 14
  claim:
    index: 16
    elements:
      identifier:
        short: GFE identifier of the originally submitted claim
        index: 17
        elements:
          system: {mustSupport: true, index: 18}
          value: {index: 19}
        required: [value]
    required: [identifier]
package_version: pct-1.0.0
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., index: 1}
  serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 0, max: 1, type: Extension, mustSupport: true, index: 2}
  outOfNetworkProviderInfo: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink', min: 0, max: 1, type: Extension, 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: 1.0.0
required: [total, benefitPeriod, processNote, claim, extension, identifier, item, benefitBalance]