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
    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: 69
        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: 70}
        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: 70
            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: 70}
                  min: 0
                  max: 1
      preAuthRef: {array: true, max: 2, index: 71}
  diagnosis:
    mustSupport: true
    index: 45
    elements:
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosisTypeVS'}
        mustSupport: true
        index: 46
    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: 47
            elements:
              sequence:
                pattern: {type: PositiveInt, value: 1}
                index: 48
              diagnosis:
                choices: [diagnosisCodeableConcept]
                index: 50
              diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 51}
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: principal, system: 'http://terminology.hl7.org/CodeSystem/ex-diagnosistype'}
                index: 52
            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: 53
            elements:
              diagnosis:
                choices: [diagnosisCodeableConcept]
                index: 55
              diagnosisCodeableConcept: {type: CodeableConcept, choiceOf: diagnosis, index: 56}
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: other, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDiagnosisType'}
                index: 57
            required: [type]
  supportingInfo:
    mustSupport: true
    index: 33
    elements:
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS'}
        index: 34
    slicing:
      rules: open
      ordered: false
      description: Slice based on $this pattern
      discriminator:
      - {path: category, type: pattern}
      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: 35
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: servicefacility, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'}
                index: 36
              value:
                choices: []
                index: 38
                slicing:
                  rules: open
                  ordered: false
                  discriminator:
                  - {path: $this, type: type}
                  min: 1
                  slices:
                    valueReference:
                      match: {}
                      schema:
                        choices: [valueReference]
                        _required: true
                        index: 40
                      min: 1
                      max: 1
              valueReference:
                type: Reference
                choiceOf: value
                refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
                index: 41
                slicing:
                  slices:
                    valueReference:
                      match: {}
                      schema:
                        type: Reference
                        choiceOf: value
                        refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
                        _required: true
                        index: 41
                      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
            mustSupport: true
            index: 42
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: claimFrequency, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType'}
                index: 43
              code:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEFrequencyVS'}
                index: 44
            required: [code]
  use:
    pattern: {type: Code, value: predetermination}
    index: 12
  item:
    array: true
    min: 1
    max: 50
    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: 78}
      gfeBillingProviderLineItemCtrlNum: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', min: 0, max: 1, type: Extension, mustSupport: true, index: 79}
      serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 80}
      ProviderEventMethodology: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/providerEventMethodology', min: 0, max: 1, short: Provider Event Methodology, type: Extension, mustSupport: true, index: 81}
    elements:
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS'}
        mustSupport: true
        array: true
        max: 4
        index: 84
      locationCodeableConcept: {type: CodeableConcept, choiceOf: location, index: 89}
      net: {short: Total charge amount for the service line, index: 92}
      serviced:
        short: This is the planned or estimated date(s)s of service
        mustSupport: true
        choices: []
        index: 86
      careTeamSequence: {mustSupport: true, index: 82}
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'}
        index: 83
      extension:
        index: 77
        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: 78}
              min: 0
              max: 11
            gfeBillingProviderLineItemCtrlNum:
              match: {url: null}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeBillingProviderLineItemCtrlNum', index: 79}
              min: 0
              max: 1
            serviceDescription:
              match: {url: null}
              schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 80}
              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: 81}
              min: 0
              max: 1
      quantity: {index: 90}
      location:
        choices: [locationCodeableConcept]
        index: 88
      unitPrice: {index: 91}
      detail:
        short: Drug Identification Information
        mustSupport: true
        index: 93
        elements:
          productOrService:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes'}
            index: 94
          quantity: {mustSupport: true, index: 95}
    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: 11
  procedure:
    mustSupport: true
    index: 58
    extensions:
      serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 60}
    elements:
      extension:
        index: 59
        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: 60}
              min: 1
              max: 1
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS'}
        mustSupport: true
        index: 61
    required: [extension]
    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: 62
            extensions:
              serviceDescription: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', min: 1, max: 1, type: Extension, index: 63}
            elements:
              extension:
                type: Extension
                url: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription
                index: 63
                slicing:
                  slices:
                    serviceDescription:
                      match: {}
                      schema: {type: Extension, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription', index: 63}
                      min: 1
                      max: 1
              type:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: procedureRequiringAnesthesia, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType'}
                index: 64
              procedure:
                choices: [procedureCodeableConcept]
                index: 66
              procedureCodeableConcept: {type: CodeableConcept, choiceOf: procedure, index: 67}
            required: [type]
        other:
          match: {type: null}
          schema: {mustSupport: true, array: true, max: 24, index: 68}
          min: 0
          max: 24
  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: 23}
    elements:
      extension:
        index: 22
        slicing:
          slices:
            referralNumber:
              match: {}
              schema: {type: Extension, short: Referral Number, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/referralNumber', index: 23}
              min: 1
              max: 1
    required: [extension]
  total: {short: Total GFE Charges Submitted, index: 96}
  insurer:
    type: Reference
    short: Required if insured estimate
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization']
    index: 14
  priority:
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    index: 19
  accident:
    elements:
      location:
        choices: [locationAddress]
        index: 73
      locationAddress: {type: Address, choiceOf: location, index: 74}
      location[x]:
        elements:
          country:
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/iso3166-1-2'}
            index: 75
  payee:
    mustSupport: true
    index: 20
    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: 21
  identifier:
    index: 4
    slicing:
      rules: open
      description: Slice based on type 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', 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-practitioner']
    index: 15
    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: 17}
      consentForBalanceBilling: {url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', min: 0, max: 1, type: Extension, mustSupport: true, index: 18}
    elements:
      extension:
        index: 16
        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: 17}
              min: 1
              max: 1
            consentForBalanceBilling:
              match: {}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeConsentForBalanceBilling', index: 18}
              min: 0
              max: 1
    required: [extension]
  careTeam:
    mustSupport: true
    index: 24
    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: 25
      role:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS'}
        index: 26
      qualification:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role'}
        index: 27
    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:
            array: true
            index: 28
            elements:
              role:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: rendering, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
                index: 29
              qualification: {short: Practitioner credential or specialization - must provide a taxonomy code for the Professional case, index: 30}
            required: [qualification]
        referring:
          match:
            role:
              coding:
              - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
          schema:
            index: 31
            elements:
              role:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: referring, system: 'http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTCareTeamRole'}
                index: 32
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-professional
base: http://hl7.org/fhir/StructureDefinition/Claim
version: 2.0.0-ballot
required: [total, diagnosis, identifier, item]