description: PCT Good Faith Estimate Institutional is a profile for capturing submission data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for an institutional GFE submission. package_name: hl7.fhir.us.davinci derivation: constraint name: PCTGFEInstitutional type: Claim elements: patient: type: Reference refers: ['http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics'] index: 13 insurance: elements: coverage: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage'] index: 107 extensions: dataAbsentReason: {url: 'http://hl7.org/fhir/StructureDefinition/data-absent-reason', min: 0, max: 1, type: Extension, short: Coverage may be not applicable if estimate is for self-pay or uninsured, mustSupport: true, index: 108} elements: extension: type: Extension short: Coverage may be not applicable if estimate is for self-pay or uninsured mustSupport: true url: http://hl7.org/fhir/StructureDefinition/data-absent-reason index: 108 slicing: slices: dataAbsentReason: match: {} schema: {type: Extension, short: Coverage may be not applicable if estimate is for self-pay or uninsured, mustSupport: true, url: 'http://hl7.org/fhir/StructureDefinition/data-absent-reason', index: 108} min: 0 max: 1 preAuthRef: {index: 109} diagnosis: mustSupport: true index: 62 elements: type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosisTypeVS'} mustSupport: true index: 63 slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: type, type: pattern} min: 1 slices: principal: match: type: coding: - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'} schema: _required: true index: 64 elements: sequence: pattern: {type: PositiveInt, value: 1} index: 65 diagnosis: choices: [diagnosisCodeableConcept] index: 67 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 68} type: pattern: type: CodeableConcept value: coding: - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'} index: 69 required: [type] admitting: match: type: coding: - {code: admitting, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'} schema: mustSupport: true index: 70 elements: diagnosis: choices: [diagnosisCodeableConcept] index: 72 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 73} type: pattern: type: CodeableConcept value: coding: - {code: admitting, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'} index: 74 required: [type] patientReasonForVisit: match: type: coding: - {code: patientReasonForVisit, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} schema: mustSupport: true array: true max: 3 index: 75 elements: diagnosis: choices: [diagnosisCodeableConcept] index: 77 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 78} type: pattern: type: CodeableConcept value: coding: - {code: patientReasonForVisit, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} index: 79 required: [type] externalcauseofinjury: match: type: coding: - {code: externalCauseOfInjury, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} schema: mustSupport: true array: true max: 12 index: 80 elements: diagnosis: choices: [diagnosisCodeableConcept] index: 82 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 83} type: pattern: type: CodeableConcept value: coding: - {code: externalCauseOfInjury, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} index: 84 required: [type] other: match: type: coding: - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} schema: mustSupport: true array: true max: 24 index: 85 elements: diagnosis: mustSupport: true choices: [diagnosisCodeableConcept] index: 87 diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 88} type: pattern: type: CodeableConcept value: coding: - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'} index: 89 required: [type] supportingInfo: mustSupport: true index: 41 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS'} index: 42 slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: category, type: pattern} min: 1 slices: typeOfBill: match: category: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: _required: true index: 43 elements: category: pattern: type: CodeableConcept value: coding: - {code: typeofbill, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 44 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFETypeOfBillVS'} index: 45 required: [code] serviceFacility: match: category: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: short: Service Facility mustSupport: true index: 46 elements: category: pattern: type: CodeableConcept value: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 47 value: choices: [] index: 49 slicing: rules: open ordered: false discriminator: - {path: $this, type: type} min: 1 slices: valueReference: match: {} schema: choices: [valueReference] _required: true index: 51 min: 1 max: 1 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] index: 52 slicing: slices: valueReference: match: {} schema: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] _required: true index: 52 min: 1 max: 1 required: [valueReference, value] drg: match: category: coding: - {code: drg, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: index: 53 elements: category: pattern: type: CodeableConcept value: coding: - {code: drg, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 54 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimDRGCodes'} index: 55 pointoforigin: match: category: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: index: 56 elements: category: pattern: type: CodeableConcept value: coding: - {code: pointoforigin, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 57 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/AHANUBCPointOfOriginVS'} index: 58 admtype: match: category: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: index: 59 elements: category: pattern: type: CodeableConcept value: coding: - {code: admtype, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 60 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisitVS'} index: 61 use: pattern: {type: Code, value: predetermination} index: 12 item: array: true min: 1 max: 999 index: 114 extensions: gfeBillingProviderLineItemCtrlNum: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', min: 0, max: 1, type: Extension, mustSupport: true, index: 116} serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 117} ProviderEventMethodology: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', min: 0, max: 1, short: Provider Event Methodology, type: Extension, mustSupport: true, index: 118} elements: modifier: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'} mustSupport: true array: true max: 4 index: 121 revenue: short: Revenue or cost center code - must provide a value for the Institutional case binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS'} index: 119 locationCodeableConcept: type: CodeableConcept mustSupport: true choiceOf: location index: 128 slicing: slices: locationCodeableConcept: match: {} schema: {type: CodeableConcept, mustSupport: true, choiceOf: location, index: 128} min: 0 max: 1 net: {short: Total charge amount for the service line, index: 130} serviced: short: This is the planned or estimated date(s)s of service mustSupport: true choices: [] index: 123 productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'} index: 120 extension: index: 115 slicing: rules: open ordered: false discriminator: - {path: url, type: value} min: 1 slices: gfeBillingProviderLineItemCtrlNum: match: {url: null} schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', index: 116} min: 0 max: 1 serviceDescription: match: {url: null} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 117} min: 1 max: 1 ProviderEventMethodology: match: {url: null} schema: {short: Provider Event Methodology, type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', index: 118} min: 0 max: 1 quantity: {index: 129} location: choices: [] index: 125 slicing: rules: open ordered: false discriminator: - {path: $this, type: type} min: null slices: locationCodeableConcept: match: {} schema: mustSupport: true choices: [locationCodeableConcept] index: 127 min: 0 max: 1 detail: short: Drug Identification Information mustSupport: true index: 131 elements: productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemNDCVS'} index: 132 quantity: {mustSupport: true, index: 133} required: [revenue, net, extension, quantity, serviced] type: pattern: type: CodeableConcept value: coding: - {code: institutional, system: 'http://terminology.hl7.org/CodeSystem/claim-type'} index: 11 procedure: mustSupport: true index: 90 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 92} elements: extension: index: 91 slicing: rules: open ordered: false discriminator: - {path: url, type: value} min: 1 slices: serviceDescription: match: {url: null} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 92} min: 1 max: 1 type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS'} mustSupport: true index: 93 required: [extension] slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: type, type: pattern} min: null slices: principal: match: type: coding: - {code: principal, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} schema: short: Principal clinical procedure performed mustSupport: true index: 94 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 95} elements: extension: type: Extension url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription index: 95 slicing: slices: serviceDescription: match: {} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 95} min: 1 max: 1 sequence: pattern: {type: PositiveInt, value: 1} index: 96 type: pattern: type: CodeableConcept value: coding: - {code: principal, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} index: 97 procedure: choices: [procedureCodeableConcept] index: 99 procedureCodeableConcept: {type: CodeableConcept, choiceOf: procedure, index: 100} required: [type] other: match: type: coding: - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} schema: mustSupport: true array: true max: 24 index: 101 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 102} elements: extension: type: Extension url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription index: 102 slicing: slices: serviceDescription: match: {} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 102} min: 1 max: 1 type: pattern: type: CodeableConcept value: coding: - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} index: 103 procedure: choices: [procedureCodeableConcept] index: 105 procedureCodeableConcept: {type: CodeableConcept, choiceOf: procedure, index: 106} required: [type] extension: index: 0 slicing: rules: open ordered: false discriminator: - {path: url, type: value} min: null slices: gfeServiceLinkingInfo: match: {url: null} schema: {type: Extension, short: GFE Service Linking Information., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo', index: 1} min: 0 max: 1 providerEventMethodology: match: {url: null} schema: {short: Provider event collection methodology, type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', index: 2} min: 0 max: 1 gfeDisclaimer: match: {url: null} schema: {type: Extension, short: Disclaimers the patient should be made aware of regarding the providers estimate, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer', index: 3} min: 0 referral: extensions: referralNumber: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', min: 1, max: 1, type: Extension, short: Referral Number, index: 24} elements: extension: index: 23 slicing: slices: referralNumber: match: {} schema: {type: Extension, short: Referral Number, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 24} min: 1 max: 1 required: [extension] total: {short: Total GFE Charges Submitted, index: 134} insurer: type: Reference short: Required if insured estimate mustSupport: true refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] index: 15 priority: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'} index: 20 accident: elements: location: choices: [locationAddress] index: 111 locationAddress: {type: Address, choiceOf: location, index: 112} location[x]: elements: country: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/iso3166-1-2'} index: 113 payee: mustSupport: true index: 21 elements: party: 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: 22 billablePeriod: {short: 'Relevant time frame for the claim. This is per claim, whereas a planned period of service can span multiple claims.', mustSupport: true, index: 14} identifier: index: 4 slicing: rules: open description: Slice based on $this pattern discriminator: - {path: type, type: pattern} min: 1 slices: PLAC: match: type: coding: - {code: PLAC, system: 'http://terminology.hl7.org/CodeSystem/v2-0203', display: Placer Identifier} schema: short: Provider Assigned Identifier for GFE Claim _required: true index: 5 elements: type: pattern: type: CodeableConcept value: coding: - {code: PLAC, system: 'http://terminology.hl7.org/CodeSystem/v2-0203', display: Placer Identifier} index: 6 system: {mustSupport: true, index: 7} value: {index: 8} required: [value, type] 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: 9 elements: type: pattern: type: CodeableConcept value: coding: - {code: INTER, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType', display: Intermediary System Identifier} index: 10 required: [type] provider: type: Reference short: Billing provider - party responsible for the GFE refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] index: 16 extensions: providerTaxonomy: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy', min: 1, max: 1, type: Extension, short: Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers, index: 18} consentForBalanceBilling: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', min: 0, max: 1, type: Extension, mustSupport: true, index: 19} elements: extension: index: 17 slicing: slices: providerTaxonomy: match: {} schema: {type: Extension, short: Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerTaxonomy', index: 18} min: 1 max: 1 consentForBalanceBilling: match: {} schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', index: 19} min: 0 max: 1 required: [extension] careTeam: mustSupport: true index: 25 elements: 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: 26 role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS'} index: 27 qualification: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role'} index: 28 required: [role] slicing: rules: open ordered: false description: Slice based on $this pattern discriminator: - {path: role, type: pattern} min: null slices: attending: match: role: coding: - {code: attending, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} schema: mustSupport: true index: 29 elements: provider: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner'] index: 30 role: pattern: type: CodeableConcept value: coding: - {code: attending, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} index: 31 qualification: {index: 32} required: [qualification] operating: match: role: coding: - {code: operating, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} schema: mustSupport: true array: true max: 2 index: 33 elements: provider: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner'] index: 34 role: pattern: type: CodeableConcept value: coding: - {code: operating, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} index: 35 rendering: match: role: coding: - {code: rendering, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} schema: mustSupport: true index: 36 elements: provider: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner'] index: 37 role: pattern: type: CodeableConcept value: coding: - {code: rendering, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} index: 38 referring: match: role: coding: - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} schema: mustSupport: true index: 39 elements: role: pattern: type: CodeableConcept value: coding: - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'} index: 40 package_version: pct-2.0.0-ballot extensions: gfeServiceLinkingInfo: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeServiceLinkingInfo', min: 0, max: 1, type: Extension, short: GFE Service Linking Information., mustSupport: true, index: 1} providerEventMethodology: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', min: 0, max: 1, short: Provider event collection methodology, type: Extension, mustSupport: true, index: 2} gfeDisclaimer: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeDisclaimer', min: 0, type: Extension, short: Disclaimers the patient should be made aware of regarding the providers estimate, mustSupport: true, index: 3} class: profile kind: resource url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-institutional base: http://hl7.org/fhir/StructureDefinition/Claim version: 2.0.0-ballot required: [total, diagnosis, supportingInfo, identifier, item]