description: This profile is used for exchanging a summary of Advanced Explanation of Benefit (AEOB) information, including costs and benefits, of all of the Advanced EOB data contained within an AEOB Packet.
package_name: hl7.fhir.us.davinci-pct
derivation: constraint
name: PCTAdvancedEOBSummary
type: ExplanationOfBenefit
elements:
  patient:
    type: Reference
    refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0']
    index: 6
  insurance:
    elements:
      coverage:
        type: Reference
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage']
        index: 32
  benefitBalance:
    short: Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
    index: 59
    elements:
      category:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS'}
        index: 60
        elements:
          text: {mustSupport: true, index: 61}
        required: [text]
      unit:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-unit'}
        index: 62
      term:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/benefit-term'}
        index: 63
      financial:
        index: 64
        extensions:
          remaining: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit', min: 0, max: 1, type: Extension, mustSupport: true, index: 66}
        elements:
          extension:
            index: 65
            slicing:
              rules: open
              ordered: false
              discriminator:
              - {path: url, type: value}
              min: null
              slices:
                remaining:
                  match: {url: null}
                  schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit', index: 66}
                  min: 0
                  max: 1
          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: 26}
  processNote:
    short: Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period,  and other legal or otherwise required disclaimers.
    index: 55
    extensions:
      processNoteClass: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass', min: 0, max: 1, type: Extension, index: 57}
    elements:
      extension:
        index: 56
        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: 57}
              min: 0
              max: 1
  preAuthRef: {index: 28}
  adjudication: {index: 35}
  enterer: {index: 9}
  supportingInfo: {index: 30}
  use:
    pattern: {type: Code, value: predetermination}
    index: 5
  payment: {index: 54}
  item: {index: 33}
  type:
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: estimate-summary, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse'}
    index: 3
  created: {short: The date and time this summary was generated., index: 8}
  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: 25}
  preAuthRefPeriod: {index: 29}
  total:
    array: true
    min: 3
    index: 36
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal'}
        mustSupport: true
        index: 37
    slicing:
      rules: open
      ordered: false
      description: Slice based on value value
      discriminator:
      - {path: category, type: value}
      min: 3
      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: 38
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 39
        memberliability:
          match:
            category:
              coding:
              - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
          schema:
            short: Total member liability
            mustSupport: true
            _required: true
            index: 40
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: memberliability, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS'}
                index: 41
        eligible:
          match:
            category:
              coding:
              - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Total eligible amount
            mustSupport: true
            _required: true
            index: 42
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: eligible, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 43
        innetwork:
          match:
            category:
              coding:
              - {code: innetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total in network amount - only include when total type is applicable
            mustSupport: true
            index: 44
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: innetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 45
        outofnetwork:
          match:
            category:
              coding:
              - {code: outofnetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total out of network amount - only include when total type is applicable
            mustSupport: true
            index: 46
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: outofnetwork, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 47
        noncovered:
          match:
            category:
              coding:
              - {code: noncovered, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication'}
          schema:
            short: Total noncovered amount - only include when total type is applicable
            mustSupport: true
            index: 48
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: noncovered, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication'}
                index: 49
        negotiated:
          match:
            category:
              coding:
              - {code: negotiated, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
          schema:
            short: Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
            mustSupport: true
            index: 50
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: negotiated, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS'}
                index: 51
        benefit:
          match:
            category:
              coding:
              - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          schema:
            short: Total benefit amount - only include when total type is applicable
            mustSupport: true
            index: 52
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: benefit, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
                index: 53
  insurer:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 10
  fundsReserve: {index: 21}
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    index: 19
  payee: {index: 24}
  prescription: {index: 22}
  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: 7}
  subType: {index: 4}
  fundsReserveRequested: {index: 20}
  benefitPeriod: {index: 58}
  precedence: {index: 31}
  provider:
    extensions:
      dataAbsentReason:
        url: http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
        type: Extension
        index: 12
        elements:
          value:
            pattern: {type: Code, value: not-applicable}
            choices: []
            index: 14
    elements:
      extension:
        index: 11
        slicing:
          slices:
            dataAbsentReason:
              match: {}
              schema:
                type: Extension
                url: http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
                index: 12
                elements:
                  value:
                    pattern: {type: Code, value: not-applicable}
                    choices: []
                    index: 14
      reference: {index: 15}
      type: {index: 16}
      identifier: {index: 17}
      display: {index: 18}
    required: [extension]
  addItem: {index: 34}
  originalPrescription: {index: 23}
  claim: {index: 27}
package_version: 2.0.0
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
required: [benefitPeriod, billablePeriod, processNote, benefitBalance]