description: PCT Good Faith Estimate Professional 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 a professional GFE submission.
package_name: hl7.fhir.us.davinci
derivation: constraint
name: PCTGFEProfessional
type: Claim
elements:
  patient:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-patient']
    index: 8
  insurance:
    elements:
      coverage:
        type: Reference
        mustSupport: true
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage']
        index: 58
      preAuthRef: {mustSupport: true, array: true, max: 2, index: 59}
  facility:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-location']
    index: 16
  diagnosis:
    mustSupport: true
    index: 31
    elements:
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosisTypeVS'}
        mustSupport: true
        index: 32
    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:
            mustSupport: true
            _required: true
            index: 33
            elements:
              sequence:
                pattern: {type: PositiveInt, value: 1}
                index: 34
              diagnosis:
                mustSupport: true
                choices: [diagnosisCodeableConcept]
                index: 36
              diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 37}
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'}
                index: 38
              packageCode: {short: For the Professional case this is the Provider GFE Grouper Methodology, mustSupport: true, index: 39}
            required: [type]
        other:
          match:
            type:
              coding:
              - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'}
          schema:
            mustSupport: true
            array: true
            max: 11
            index: 40
            elements:
              diagnosis:
                mustSupport: true
                choices: [diagnosisCodeableConcept]
                index: 42
              diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 43}
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'}
                index: 44
              packageCode: {short: For the Professional case this is the Provider GFE Grouper Methodology, mustSupport: true, index: 45}
            required: [type]
  supportingInfo:
    mustSupport: true
    index: 26
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS'}
        index: 27
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: category, type: pattern}
      min: null
      slices:
        placeOfService:
          match:
            category:
              coding:
              - {code: cmspos, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType', display: CMS Place of Service}
          schema:
            mustSupport: true
            index: 28
            elements:
              category:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: cmspos, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType', display: CMS Place of Service}
                index: 29
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFECMSPOS'}
                mustSupport: true
                index: 30
            required: [code]
  use:
    pattern: {type: Code, value: predetermination}
    index: 7
  item:
    min: 1
    index: 60
    mustSupport: true
    array: true
    elements:
      extension:
        index: 61
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            referralNumber:
              match: {url: null}
              schema: {type: Extension, short: Referral Number, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 62}
              min: 0
              max: 11
            estimatedDateOfService:
              match: {url: null}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService', index: 63}
              min: 0
              max: 1
            gfeBillingProviderLineItemCtrlNum:
              match: {url: null}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', index: 64}
              min: 0
              max: 1
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        index: 65
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        mustSupport: true
        array: true
        max: 4
        index: 66
      location:
        choices: []
        index: 68
      locationCodeableConcept:
        type: CodeableConcept
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFECMSPOS'}
        mustSupport: true
        index: 69
      quantity: {mustSupport: true, index: 70}
      net: {mustSupport: true, index: 71}
      detail:
        short: Drug Identification Information
        mustSupport: true
        index: 72
        extensions:
          compoundDrugLinkingNumber: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/compoundDrugLinkingNum', min: 0, max: 1, short: Compound Drug Linking Number, type: Extension, mustSupport: true, index: 74}
        elements:
          extension:
            index: 73
            slicing:
              rules: open
              ordered: false
              discriminator:
              - {path: url, type: value}
              min: null
              slices:
                compoundDrugLinkingNumber:
                  match: {url: null}
                  schema: {short: Compound Drug Linking Number, type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/compoundDrugLinkingNum', index: 74}
                  min: 0
                  max: 1
          productOrService:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemNDCVS'}
            index: 75
          quantity: {mustSupport: true, index: 76}
    extensions:
      referralNumber: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', min: 0, max: 11, type: Extension, short: Referral Number, mustSupport: true, index: 62}
      estimatedDateOfService: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimatedDateOfService', min: 0, max: 1, type: Extension, mustSupport: true, index: 63}
      gfeBillingProviderLineItemCtrlNum: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', min: 0, max: 1, type: Extension, mustSupport: true, index: 64}
    max: 50
    required: [net, quantity, location, locationCodeableConcept]
  type:
    pattern:
      type: CodeableConcept
      value:
        coding:
        - {code: professional, system: 'http://terminology.hl7.org/CodeSystem/claim-type', display: Professional}
    index: 6
  procedure:
    mustSupport: true
    index: 46
    elements:
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS'}
        mustSupport: true
        index: 47
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: type, type: pattern}
      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: 48
            elements:
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: procedureRequiringAnesthesia, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'}
                index: 49
              procedure:
                mustSupport: true
                choices: [procedureCodeableConcept]
                index: 51
              procedureCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: procedure, index: 52}
            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: 53
            elements:
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'}
                index: 54
              procedure:
                mustSupport: true
                choices: [procedureCodeableConcept]
                index: 56
              procedureCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: procedure, index: 57}
            required: [type]
  extension:
    array: true
    min: 2
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: 2
      slices:
        gfeSubmitter:
          match: {url: null}
          schema: {type: Extension, short: The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter', index: 1}
          min: 1
          max: 1
        gfeProviderAssignedIdentifier:
          match: {url: null}
          schema: {type: Extension, short: GFE Provider Assigned Identifier, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeProviderAssignedIdentifier', index: 2}
          min: 1
          max: 1
        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: 3}
          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: 4}
          min: 0
          max: 1
        interTransIdentifier:
          match: {url: null}
          schema: {short: Intermediary Transmission Identifier, type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/interTransIdentifier', index: 5}
          min: 0
          max: 1
  referral:
    extensions:
      referralNumber: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', min: 1, max: 1, type: Extension, short: Referral Number, mustSupport: true, index: 15}
    elements:
      extension:
        index: 14
        slicing:
          slices:
            referralNumber:
              match: {}
              schema: {type: Extension, short: Referral Number, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 15}
              min: 1
              max: 1
    required: [extension]
  total: {short: Total GFE Charges Submitted, index: 77}
  insurer:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 9
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    mustSupport: true
    index: 11
  payee:
    mustSupport: true
    index: 12
    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: 13
  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-practitionerrole']
    index: 10
  careTeam:
    mustSupport: true
    index: 17
    elements:
      provider:
        type: Reference
        mustSupport: true
        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization', 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner']
        index: 18
      role:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS'}
        mustSupport: true
        index: 19
      qualification:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role'}
        mustSupport: true
        index: 20
    required: [role]
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: role, type: pattern}
      min: null
      slices:
        rendering:
          match:
            role:
              coding:
              - {code: rendering, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
          schema:
            mustSupport: true
            array: true
            max: 2
            index: 21
            elements:
              role:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: rendering, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
                index: 22
              qualification: {short: Practitioner credential or specialization - must provide a taxonomy code for the Professional case, index: 23}
            required: [qualification]
        referring:
          match:
            role:
              coding:
              - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
          schema:
            mustSupport: true
            index: 24
            elements:
              role:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
                index: 25
package_version: pct-0.1.0
extensions:
  gfeSubmitter: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter', min: 1, max: 1, type: Extension, short: The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB, mustSupport: true, index: 1}
  gfeProviderAssignedIdentifier: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeProviderAssignedIdentifier', min: 1, max: 1, type: Extension, short: GFE Provider Assigned Identifier, mustSupport: true, index: 2}
  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: 3}
  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: 4}
  interTransIdentifier: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/interTransIdentifier', min: 0, max: 1, short: Intermediary Transmission Identifier, type: Extension, mustSupport: true, index: 5}
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: 0.1.0
required: [total, insurer, diagnosis, item]