PCTAdvancedEOB

PCT Advanced EOB

activeDa Vinci PCT2.0.1resource59 key elements

The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob
ID
davinci-pct-aeob
Type
Base Definition
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
extension
1+
:gfeReference1..*
Extension
1+
The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
:serviceDescription0..1
Extension
S
:outOfNetworkProviderInfo0..1
Extension
S
identifier
1+
:uniqueclaimid1..1
1+
Unique Claim ID
identifier.type
1+
priority
S
claim
1+
claim.identifier
1+
GFE identifier of the originally submitted claim
claim.identifier.system
S
claim.identifier.value
1+
item
1+
:serviceDescription0..1
Extension
S
item.modifier
S
item.serviced[x]
1+
This is the planned or estimated date(s)s of service
item.quantity
S
item.adjudication
S1+
:medicalmanagement0..*
S
item.adjudication.extension
1+
:subjectToMedicalMgmt1..1
Extension
1+
:benefitpaymentstatus0..1
S
Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
:adjustmentreason0..*
S
Adjustment Reason
:submitted0..1
S
Provider submitted amount
:memberliability0..1
S
Member liability
:eligible0..1
S
Eligible amount
:benefit0..1
S
Benefit amount
adjudication
BackboneElement
S
:medicalmanagement0..*
BackboneElement
S
adjudication.extension
1+
:subjectToMedicalMgmt1..1
Extension
1+
:billingnetworkstatus0..1
BackboneElement
S
Billing Provider Network Status
:renderingnetworkstatus0..1
BackboneElement
S
Rendering Provider Network Status
:benefitpaymentstatus0..1
BackboneElement
S
Benefit Payment Status
:adjustmentreason0..*
BackboneElement
S
Adjustment Reason
:submitted0..1
BackboneElement
S
Provider submitted amount
:memberliability0..1
BackboneElement
S
Member liability
:eligible0..1
BackboneElement
S
Eligible amount
:benefit0..1
BackboneElement
S
Benefit amount
total
1+
total.category
S
:submitted1..1
S1+
Total provider submitted amount
:memberliability1..1
S1+
Total member liability
:eligible1..1
S1+
Total eligible amount
:innetwork0..1
S
Total in network amount - only include when total type is applicable
:outofnetwork0..1
S
Total out of network amount - only include when total type is applicable
:noncovered0..1
S
Total noncovered amount - only include when total type is applicable
:negotiated0..1
S
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
:benefit0..1
S
Total benefit amount - only include when total type is applicable
processNote
1+
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.
benefitPeriod
1+
benefitBalance
1+
Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
benefitBalance.category.text
S1+
benefitBalance.unit
1+
benefitBalance.term
1+
benefitBalance.financial
1+
:remaining0..1
Extension
S
benefitBalance.financial.allowed[x]
unsignedIntMoney
S1+
benefitBalance.financial.used[x]
unsignedIntMoney
S1+