description: PCT Good Faith Estimate Professional is a profile for an professional provider to capture estimation for items and services for the patient or, optionally, to submit to a payer (for patients using insurance). If submitting to a payer, this includes the data needed to be processed by a payer for the creation of an Advanced EOB. This profile is used for a professional GFE submission. package_name: hl7.fhir.us.davinci-pct derivation: constraint name: PCTGFEProfessional type: Claim elements: patient: type: Reference refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0'] index: 11 insurance: elements: coverage: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage'] index: 72 extensions: dataAbsentReason: {url: 'http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0', min: 0, max: 1, type: Extension, short: Coverage may be not applicable if estimate is for self-pay or uninsured, mustSupport: true, index: 73} 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|5.2.0 index: 73 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|5.2.0', index: 73} min: 0 max: 1 preAuthRef: {array: true, max: 2, index: 74} diagnosis: mustSupport: true index: 43 elements: type: binding: {strength: required, valueSet: 'http://terminology.hl7.org/ValueSet/diagnosistype'} mustSupport: true index: 44 slicing: rules: open ordered: false description: Slice based on $this value discriminator: - {path: type, type: value} min: null slices: principal: match: type: coding: - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/diagnosistype'} schema: short: Principal Diagnosis - Must Support means the information source SHALL be capable of populating and SHALL populate if available and permitted. mustSupport: true index: 45 elements: sequence: pattern: {type: PositiveInt, value: 1} index: 46 diagnosis: choices: [diagnosisCodeableConcept] index: 48 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 49} type: pattern: type: CodeableConcept value: coding: - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/diagnosistype'} index: 50 required: [type] other: match: type: coding: - {code: secondary, system: 'http://terminology.hl7.org/CodeSystem/diagnosistype'} schema: mustSupport: true array: true max: 11 index: 51 elements: diagnosis: choices: [diagnosisCodeableConcept] index: 53 diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 54} type: pattern: type: CodeableConcept value: coding: - {code: secondary, system: 'http://terminology.hl7.org/CodeSystem/diagnosistype'} index: 55 required: [type] supportingInfo: mustSupport: true index: 31 elements: category: binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS'} index: 32 slicing: rules: open ordered: false description: Slice based on $this value discriminator: - {path: category, type: value} min: null slices: serviceFacility: match: category: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: short: Service Facility mustSupport: true index: 33 elements: category: pattern: type: CodeableConcept value: coding: - {code: servicefacility, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 34 value: choices: [] index: 36 slicing: rules: open ordered: false discriminator: - {path: $this, type: type} min: 1 slices: valueReference: match: {} schema: choices: [valueReference] _required: true index: 38 min: 1 max: 1 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] index: 39 slicing: slices: valueReference: match: {} schema: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] _required: true index: 39 min: 1 max: 1 required: [valueReference, value] claimFrequency: match: category: coding: - {code: claimFrequency, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} schema: short: Claim Frequency component of the UB-04 Type of Bill Code (4th digit of the UB-04 Type of Bill code). mustSupport: true index: 40 elements: category: pattern: type: CodeableConcept value: coding: - {code: claimFrequency, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'} index: 41 code: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFETypeOfBillVS'} index: 42 required: [code] use: pattern: {type: Code, value: predetermination} index: 10 item: array: true min: 1 max: 50 index: 79 extensions: referralNumber: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', min: 0, max: 11, type: Extension, short: Referral Number, mustSupport: true, index: 81} gfeBillingProviderLineItemCtrlNum: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', min: 0, max: 1, type: Extension, mustSupport: true, index: 82} serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 83} ProviderEventMethodology: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', min: 0, max: 1, short: Provider Event Methodology, type: Extension, mustSupport: true, index: 84} elements: modifier: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'} mustSupport: true array: true max: 4 index: 88 elements: coding: constraint: pct-cpt-display: {human: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended), source: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional', severity: error, expression: 'system = ''http://www.ama-assn.org/go/cpt'' implies display.exists()'} index: 89 locationCodeableConcept: {type: CodeableConcept, choiceOf: location, index: 94} net: {short: Total charge amount for the service line, index: 97} serviced: short: This is the planned or estimated date(s)s of service mustSupport: true choices: [] index: 91 careTeamSequence: {mustSupport: true, index: 85} productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'} index: 86 elements: coding: constraint: pct-cpt-display: {human: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended), source: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional', severity: error, expression: 'system = ''http://www.ama-assn.org/go/cpt'' implies display.exists()'} index: 87 extension: index: 80 slicing: rules: open ordered: false discriminator: - {path: url, type: value} min: 1 slices: referralNumber: match: {url: null} schema: {type: Extension, short: Referral Number, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 81} min: 0 max: 11 gfeBillingProviderLineItemCtrlNum: match: {url: null} schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', index: 82} min: 0 max: 1 serviceDescription: match: {url: null} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 83} 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: 84} min: 0 max: 1 quantity: {index: 95} location: choices: [locationCodeableConcept] index: 93 unitPrice: {index: 96} detail: short: Drug Identification Information mustSupport: true index: 98 elements: productOrService: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'} index: 99 quantity: {mustSupport: true, index: 100} required: [net, extension, quantity, location, serviced, unitPrice, locationCodeableConcept] type: pattern: type: CodeableConcept value: coding: - {code: professional, system: 'http://terminology.hl7.org/CodeSystem/claim-type'} index: 9 procedure: mustSupport: true index: 56 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 58} elements: extension: index: 57 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: 58} min: 1 max: 1 type: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS'} mustSupport: true index: 59 required: [extension] slicing: rules: open ordered: false description: Slice based on $this value discriminator: - {path: type, type: value} min: null slices: anesthesiaRelated: match: type: coding: - {code: procedureRequiringAnesthesia, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} schema: mustSupport: true array: true max: 2 index: 60 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 61} elements: extension: type: Extension url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription index: 61 slicing: slices: serviceDescription: match: {} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 61} min: 1 max: 1 type: pattern: type: CodeableConcept value: coding: - {code: procedureRequiringAnesthesia, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} index: 62 procedure: choices: [procedureCodeableConcept] index: 64 procedureCodeableConcept: {type: CodeableConcept, choiceOf: procedure, index: 65} 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: 66 extensions: serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 67} elements: extension: type: Extension url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription index: 67 slicing: slices: serviceDescription: match: {} schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 67} min: 1 max: 1 type: pattern: type: CodeableConcept value: coding: - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'} index: 68 procedure: choices: [procedureCodeableConcept] index: 70 procedureCodeableConcept: {type: CodeableConcept, choiceOf: procedure, index: 71} 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: {short: 'Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients', type: Extension, 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: 21} elements: extension: index: 20 slicing: slices: referralNumber: match: {} schema: {type: Extension, short: Referral Number, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 21} min: 1 max: 1 required: [extension] total: {short: Total GFE Charges Submitted, index: 101} insurer: type: Reference refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization'] index: 12 priority: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'} index: 17 accident: elements: location: choices: [locationAddress] index: 76 locationAddress: {type: Address, choiceOf: location, index: 77} location[x]: elements: country: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/iso3166-1-2'} index: 78 payee: mustSupport: true index: 18 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: 19 identifier: index: 4 slicing: rules: open description: Slice based on type value discriminator: - {path: type, type: value} 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] provider: type: Reference short: Billing provider - party responsible for the GFE refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization', 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner'] index: 13 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: 15} consentForBalanceBilling: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', min: 0, max: 1, type: Extension, mustSupport: true, index: 16} elements: extension: index: 14 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: 15} min: 1 max: 1 consentForBalanceBilling: match: {} schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', index: 16} min: 0 max: 1 required: [extension] careTeam: mustSupport: true index: 22 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: 23 role: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS'} index: 24 qualification: binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role'} index: 25 required: [role] slicing: rules: open ordered: false description: Slice based on $this value discriminator: - {path: role, type: value} min: null slices: rendering: match: role: coding: - {code: rendering, system: 'http://terminology.hl7.org/CodeSystem/claimcareteamrole', version: 1.0.1} schema: mustSupport: true array: true index: 26 elements: role: pattern: type: CodeableConcept value: coding: - {code: rendering, system: 'http://terminology.hl7.org/CodeSystem/claimcareteamrole', version: 1.0.1} index: 27 qualification: {short: Practitioner credential or specialization - must provide a taxonomy code for the Professional case, index: 28} required: [qualification] referring: match: role: coding: - {code: referring, system: 'http://terminology.hl7.org/CodeSystem/claimcareteamrole', version: 1.0.1} schema: mustSupport: true index: 29 elements: role: pattern: type: CodeableConcept value: coding: - {code: referring, system: 'http://terminology.hl7.org/CodeSystem/claimcareteamrole', version: 1.0.1} index: 30 package_version: 2.0.0 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, short: 'Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients', type: Extension, mustSupport: true, index: 3} class: profile kind: resource url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-gfe-professional base: http://hl7.org/fhir/StructureDefinition/Claim version: 2.0.0 required: [total, identifier, item]