FHIR CI-Build
FoundationThis is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
| Responsible Owner: Financial Management Work Group | Standards Status: Informative | Compartments: Device, Encounter, Group, Patient, Practitioner, RelatedPerson |
ShEx statement for explanationofbenefit
PREFIX fhir: <http://hl7.org/fhir/>
PREFIX fhirvs: <http://hl7.org/fhir/ValueSet/>
PREFIX xsd: <http://www.w3.org/2001/XMLSchema#>
PREFIX rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#>
# ShEx Version 2.2
IMPORT <Id.shex>
IMPORT <Oid.shex>
IMPORT <Uri.shex>
IMPORT <Url.shex>
IMPORT <Age.shex>
IMPORT <Code.shex>
IMPORT <Date.shex>
IMPORT <Time.shex>
IMPORT <Uuid.shex>
IMPORT <Meta.shex>
IMPORT <Group.shex>
IMPORT <Claim.shex>
IMPORT <Money.shex>
IMPORT <Count.shex>
IMPORT <Range.shex>
IMPORT <Ratio.shex>
IMPORT <String.shex>
IMPORT <Period.shex>
IMPORT <Timing.shex>
IMPORT <Coding.shex>
IMPORT <Dosage.shex>
IMPORT <Device.shex>
IMPORT <Patient.shex>
IMPORT <Address.shex>
IMPORT <Decimal.shex>
IMPORT <Boolean.shex>
IMPORT <Instant.shex>
IMPORT <Integer.shex>
IMPORT <DateTime.shex>
IMPORT <Location.shex>
IMPORT <Quantity.shex>
IMPORT <Markdown.shex>
IMPORT <Distance.shex>
IMPORT <Duration.shex>
IMPORT <Coverage.shex>
IMPORT <Reference.shex>
IMPORT <Condition.shex>
IMPORT <Procedure.shex>
IMPORT <Canonical.shex>
IMPORT <Integer64.shex>
IMPORT <HumanName.shex>
IMPORT <Signature.shex>
IMPORT <Encounter.shex>
IMPORT <Identifier.shex>
IMPORT <Attachment.shex>
IMPORT <Annotation.shex>
IMPORT <RatioRange.shex>
IMPORT <Expression.shex>
IMPORT <PositiveInt.shex>
IMPORT <UnsignedInt.shex>
IMPORT <SampledData.shex>
IMPORT <Practitioner.shex>
IMPORT <Organization.shex>
IMPORT <Base64Binary.shex>
IMPORT <ContactPoint.shex>
IMPORT <UsageContext.shex>
IMPORT <Availability.shex>
IMPORT <RelatedPerson.shex>
IMPORT <DeviceRequest.shex>
IMPORT <ClaimResponse.shex>
IMPORT <ContactDetail.shex>
IMPORT <DomainResource.shex>
IMPORT <ServiceRequest.shex>
IMPORT <NutritionOrder.shex>
IMPORT <CodeableConcept.shex>
IMPORT <BackboneElement.shex>
IMPORT <DataRequirement.shex>
IMPORT <RelatedArtifact.shex>
IMPORT <PractitionerRole.shex>
IMPORT <MedicationRequest.shex>
IMPORT <CodeableReference.shex>
IMPORT <TriggerDefinition.shex>
IMPORT <VisionPrescription.shex>
IMPORT <ParameterDefinition.shex>
IMPORT <VirtualServiceDetail.shex>
IMPORT <ExtendedContactDetail.shex>
start=@<ExplanationOfBenefit> AND {fhir:nodeRole [fhir:treeRoot]}
# Explanation of Benefit resource
<ExplanationOfBenefit> EXTENDS @<DomainResource> CLOSED {
a [fhir:ExplanationOfBenefit]?;fhir:nodeRole [fhir:treeRoot]?;
fhir:identifier @<OneOrMore_Identifier>?; # Business Identifier for the
# resource
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:status @<Code> AND
{fhir:v @fhirvs:explanationofbenefit-status}; # active | cancelled | draft |
# entered-in-error
fhir:statusReason @<String>?; # Reason for status change
fhir:type @<CodeableConcept>; # Category or discipline
fhir:subType @<CodeableConcept>?; # More granular claim type
fhir:use @<Code> AND
{fhir:v @fhirvs:claim-use}; # claim | preauthorization |
# predetermination
fhir:subject @<Reference> AND {fhir:l
@<Group> OR
@<Patient> ? }; # The recipient(s) of the products
# and services
fhir:billablePeriod @<Period>?; # Relevant time frame for the claim
fhir:created @<DateTime>; # Response creation date
fhir:enterer @<Reference> AND {fhir:l
@<Patient> OR
@<Practitioner> OR
@<PractitionerRole> OR
@<RelatedPerson> ? }?; # Author of the claim
fhir:insurer @<Reference> AND {fhir:l
@<Organization> ? }?; # Party responsible for reimbursement
fhir:provider @<Reference> AND {fhir:l
@<Organization> OR
@<Practitioner> OR
@<PractitionerRole> ? }?; # Party responsible for the claim
fhir:priority @<CodeableConcept>?; # Desired processing urgency
fhir:fundsReserveRequested @<CodeableConcept>?; # For whom to reserve funds
fhir:fundsReserve @<CodeableConcept>?; # Funds reserved status
fhir:related @<OneOrMore_ExplanationOfBenefit.related>?; # Prior or corollary claims
fhir:prescription @<Reference> AND {fhir:l
@<DeviceRequest> OR
@<MedicationRequest> OR
@<ServiceRequest> OR
@<VisionPrescription> ? }?; # Prescription authorizing services
# or products
fhir:originalPrescription @<Reference> AND {fhir:l
@<DeviceRequest> OR
@<MedicationRequest> OR
@<ServiceRequest> OR
@<VisionPrescription> ? }?; # Original prescription if
# superceded by fulfiller
fhir:event @<OneOrMore_ExplanationOfBenefit.event>?; # Event information
fhir:payee @<ExplanationOfBenefit.payee>?; # Recipient of benefits payable
fhir:referral @<Reference> AND {fhir:l
@<ServiceRequest> ? }?; # Treatment Referral
fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the
# listed treatments
fhir:facility @<Reference> AND {fhir:l
@<Location> OR
@<Organization> ? }?; # Servicing Facility
fhir:claim @<Reference> AND {fhir:l
@<Claim> ? }?; # Claim reference
fhir:claimResponse @<Reference> AND {fhir:l
@<ClaimResponse> ? }?; # Claim response reference
fhir:outcome @<Code> AND
{fhir:v @fhirvs:claim-outcome}; # queued | complete | error | partial
fhir:decision @<CodeableConcept>?; # Result of the adjudication
fhir:disposition @<String>?; # Disposition Message
fhir:preAuthRef @<OneOrMore_String>?; # Preauthorization reference
fhir:preAuthRefPeriod @<OneOrMore_Period>?; # Preauthorization in-effect period
fhir:diagnosisRelatedGroup @<CodeableConcept>?; # Package billing code
fhir:careTeam @<OneOrMore_ExplanationOfBenefit.careTeam>?; # Care Team members
fhir:supportingInfo @<OneOrMore_ExplanationOfBenefit.supportingInfo>?; # Supporting information
fhir:diagnosis @<OneOrMore_ExplanationOfBenefit.diagnosis>?; # Pertinent diagnosis information
fhir:procedure @<OneOrMore_ExplanationOfBenefit.procedure>?; # Clinical procedures performed
fhir:precedence @<PositiveInt>?; # Precedence (primary, secondary,
# etc.)
fhir:insurance @<OneOrMore_ExplanationOfBenefit.insurance>?; # Patient insurance information
fhir:accident @<ExplanationOfBenefit.accident>?; # Details of the event
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:item @<OneOrMore_ExplanationOfBenefit.item>?; # Product or service provided
fhir:addItem @<OneOrMore_ExplanationOfBenefit.addItem>?; # Insurer added line items
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Header-level adjudication
fhir:total @<OneOrMore_ExplanationOfBenefit.total>?; # Adjudication totals
fhir:payment @<ExplanationOfBenefit.payment>?; # Payment Details
fhir:formCode @<CodeableConcept>?; # Printed form identifier
fhir:form @<Attachment>?; # Printed reference or actual form
fhir:processNote @<OneOrMore_ExplanationOfBenefit.processNote>?; # Note concerning adjudication
fhir:benefitPeriod @<Period>?; # When the benefits are applicable
fhir:benefitBalance @<OneOrMore_ExplanationOfBenefit.benefitBalance>?; # Balance by Benefit Category
}
# Insurer added line items
<ExplanationOfBenefit.addItem> EXTENDS @<BackboneElement> CLOSED {
fhir:itemSequence @<OneOrMore_PositiveInt>?; # Item sequence number
fhir:detailSequence @<OneOrMore_PositiveInt>?; # Detail sequence number
fhir:subDetailSequence @<OneOrMore_PositiveInt>?; # Subdetail sequence number
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:subject @<Reference> AND {fhir:l
@<Group> OR
@<Patient> ? }?; # The recipient of the products and
# services
fhir:informationSequence @<OneOrMore_PositiveInt>?; # Applicable exception and
# supporting information
fhir:provider @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole>?; # Authorized providers
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:category @<CodeableConcept>?; # Benefit classification
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription>?; # Request or Referral for Service
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is
# provided under
fhir:serviced @<Date> OR
@<Period> ?; # Date or dates of service or
# product delivery
fhir:location @<CodeableConcept> OR
@<Address> OR
(@<Reference> AND {fhir:l @<Location> }) ?; # Place of service or where product
# was supplied
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:bodySite @<OneOrMore_ExplanationOfBenefit.addItem.bodySite>?; # Anatomical location
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem level adjudication results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication
fhir:detail @<OneOrMore_ExplanationOfBenefit.addItem.detail>?; # Insurer added line items
}
# Note concerning adjudication
<ExplanationOfBenefit.processNote> EXTENDS @<BackboneElement> CLOSED {
fhir:class @<CodeableConcept>?; # Business kind of note
fhir:number @<PositiveInt>?; # Note instance identifier
fhir:type @<CodeableConcept>?; # Note purpose
fhir:text @<Markdown>?; # Note explanatory text
fhir:language @<CodeableConcept>?; # Language of the text
}
# Benefit Summary
<ExplanationOfBenefit.benefitBalance.financial> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>; # Benefit classification
fhir:allowed @<UnsignedInt> OR
@<String> OR
@<Money> ?; # Benefits allowed
fhir:used @<UnsignedInt> OR
@<Money> ?; # Benefits used
}
# Additional items
<ExplanationOfBenefit.item.detail.subDetail> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Product or service provided
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:category @<CodeableConcept>?; # Benefit classification
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is
# provided under
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Subdetail level adjudication
# results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Subdetail level adjudication
# details
}
# Balance by Benefit Category
<ExplanationOfBenefit.benefitBalance> EXTENDS @<BackboneElement> CLOSED {
fhir:category @<CodeableConcept>; # Benefit classification
fhir:excluded @<Boolean>?; # Excluded from the plan
fhir:name @<String>?; # Short name for the benefit
fhir:description @<String>?; # Description of the benefit or
# services covered
fhir:network @<CodeableConcept>?; # In or out of network
fhir:unit @<CodeableConcept>?; # Individual or family
fhir:term @<CodeableConcept>?; # Annual or lifetime
fhir:financial @<OneOrMore_ExplanationOfBenefit.benefitBalance.financial>?; # Benefit Summary
}
# Recipient of benefits payable
<ExplanationOfBenefit.payee> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>?; # Category of recipient
fhir:party @<Reference> AND {fhir:l
@<Organization> OR
@<Patient> OR
@<Practitioner> OR
@<PractitionerRole> OR
@<RelatedPerson> ? }?; # Recipient reference
}
# Pertinent diagnosis information
<ExplanationOfBenefit.diagnosis> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Diagnosis instance identifier
fhir:diagnosis @<CodeableConcept> OR
(@<Reference> AND {fhir:l @<Condition> }) ; # Nature of illness or problem
fhir:type @<OneOrMore_CodeableConcept>?; # Timing or nature of the diagnosis
fhir:onAdmission @<CodeableConcept>?; # Present on admission
}
# Details of the event
<ExplanationOfBenefit.accident> EXTENDS @<BackboneElement> CLOSED {
fhir:date @<Date>?; # When the incident occurred
fhir:type @<CodeableConcept>?; # The nature of the accident
fhir:location @<Address> OR
(@<Reference> AND {fhir:l @<Location> }) ?; # Where the event occurred
}
# Insurer added line items
<ExplanationOfBenefit.addItem.detail.subDetail> EXTENDS @<BackboneElement> CLOSED {
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem subdetail level
# adjudication results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication
}
# Payment Details
<ExplanationOfBenefit.payment> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>?; # Partial or complete payment
fhir:adjustment @<Money>?; # Payment adjustment for non-claim
# issues
fhir:adjustmentReason @<CodeableConcept>?; # Explanation for the variance
fhir:date @<Date>?; # Expected date of payment
fhir:amount @<Money>?; # Payable amount after adjustment
fhir:identifier @<Identifier>?; # Business identifier for the payment
}
# Clinical procedures performed
<ExplanationOfBenefit.procedure> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Procedure instance identifier
fhir:type @<OneOrMore_CodeableConcept>?; # Category of Procedure
fhir:date @<DateTime>?; # When the procedure was performed
fhir:procedure @<CodeableConcept> OR
(@<Reference> AND {fhir:l @<Procedure> }) ; # Specific clinical procedure
fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier
}
# Care Team members
<ExplanationOfBenefit.careTeam> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Order of care team
fhir:provider @<Reference> AND {fhir:l
@<Organization> OR
@<Practitioner> OR
@<PractitionerRole> ? }; # Practitioner or organization
fhir:role @<CodeableConcept>?; # Function within the team
fhir:specialty @<CodeableConcept>?; # Practitioner or provider
# specialization
}
# Adjudication totals
<ExplanationOfBenefit.total> EXTENDS @<BackboneElement> CLOSED {
fhir:category @<CodeableConcept>; # Type of adjudication information
fhir:amount @<Money>; # Financial total for the category
}
# Supporting information
<ExplanationOfBenefit.supportingInfo> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Information instance identifier
fhir:category @<CodeableConcept>; # Classification of the supplied
# information
fhir:code @<CodeableConcept>?; # Type of information
fhir:timing @<DateTime> OR
@<Period> OR
@<Timing> ?; # When it occurred
fhir:value @<Base64Binary> OR
@<Boolean> OR
@<Canonical> OR
@<Code> OR
@<Date> OR
@<DateTime> OR
@<Decimal> OR
@<Id> OR
@<Instant> OR
@<Integer> OR
@<Integer64> OR
@<Markdown> OR
@<Oid> OR
@<PositiveInt> OR
@<String> OR
@<Time> OR
@<UnsignedInt> OR
@<Uri> OR
@<Url> OR
@<Uuid> OR
@<Address> OR
@<Age> OR
@<Annotation> OR
@<Attachment> OR
@<CodeableConcept> OR
@<CodeableReference> OR
@<Coding> OR
@<ContactPoint> OR
@<Count> OR
@<Distance> OR
@<Duration> OR
@<HumanName> OR
@<Identifier> OR
@<Money> OR
@<Period> OR
@<Quantity> OR
@<Range> OR
@<Ratio> OR
@<RatioRange> OR
@<Reference> OR
@<SampledData> OR
@<Signature> OR
@<Timing> OR
@<ContactDetail> OR
@<DataRequirement> OR
@<Expression> OR
@<ParameterDefinition> OR
@<RelatedArtifact> OR
@<TriggerDefinition> OR
@<UsageContext> OR
@<Availability> OR
@<ExtendedContactDetail> OR
@<VirtualServiceDetail> OR
@<Dosage> OR
@<Meta> ?; # Data to be provided
fhir:reason @<Coding>?; # Explanation for the information
}
# Patient insurance information
<ExplanationOfBenefit.insurance> EXTENDS @<BackboneElement> CLOSED {
fhir:focal @<Boolean>; # Coverage to be used for
# adjudication
fhir:coverage @<Reference> AND {fhir:l
@<Coverage> ? }; # Insurance information
fhir:preAuthRef @<OneOrMore_String>?; # Prior authorization reference
# number
}
# Event information
<ExplanationOfBenefit.event> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>; # Specific event
fhir:when @<DateTime> OR
@<Period> ; # Occurance date or period
}
# Anatomical location
<ExplanationOfBenefit.item.bodySite> EXTENDS @<BackboneElement> CLOSED {
fhir:site @<OneOrMore_CodeableReference>; # Location
fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location
}
# Prior or corollary claims
<ExplanationOfBenefit.related> EXTENDS @<BackboneElement> CLOSED {
fhir:claim @<Reference> AND {fhir:l
@<Claim> OR
@<ExplanationOfBenefit> ? }?; # Reference to the related claim
fhir:relationship @<CodeableConcept>?; # How the reference claim is related
fhir:reference @<Identifier>?; # File or case reference
}
# Adjudication results
<ExplanationOfBenefit.item.reviewOutcome> EXTENDS @<BackboneElement> CLOSED {
fhir:decision @<CodeableConcept>?; # Result of the adjudication
fhir:reason @<OneOrMore_CodeableConcept>?; # Reason for result of the
# adjudication
fhir:preAuthRef @<String>?; # Preauthorization reference
fhir:preAuthPeriod @<Period>?; # Preauthorization reference
# effective period
}
# Product or service provided
<ExplanationOfBenefit.item> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Item instance identifier
fhir:careTeamSequence @<OneOrMore_PositiveInt>?; # Applicable care team members
fhir:diagnosisSequence @<OneOrMore_PositiveInt>?; # Applicable diagnoses
fhir:procedureSequence @<OneOrMore_PositiveInt>?; # Applicable procedures
fhir:informationSequence @<OneOrMore_PositiveInt>?; # Applicable exception and
# supporting information
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:subject @<Reference> AND {fhir:l
@<Group> OR
@<Patient> ? }?; # The recipient of the products and
# services
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:category @<CodeableConcept>?; # Benefit classification
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription>?; # Request or Referral for Service
fhir:modifier @<OneOrMore_CodeableConcept>?; # Product or service billing
# modifiers
fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is
# provided under
fhir:serviced @<Date> OR
@<Period> ?; # Date or dates of service or
# product delivery
fhir:location @<CodeableConcept> OR
@<Address> OR
(@<Reference> AND {fhir:l @<Location> }) ?; # Place of service or where product
# was supplied
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier
fhir:bodySite @<OneOrMore_ExplanationOfBenefit.item.bodySite>?; # Anatomical location
fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the
# listed treatments
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Adjudication results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Adjudication details
fhir:detail @<OneOrMore_ExplanationOfBenefit.item.detail>?; # Additional items
}
# Anatomical location
<ExplanationOfBenefit.addItem.bodySite> EXTENDS @<BackboneElement> CLOSED {
fhir:site @<OneOrMore_CodeableReference>; # Location
fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location
}
# Insurer added line items
<ExplanationOfBenefit.addItem.detail> EXTENDS @<BackboneElement> CLOSED {
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Additem detail level adjudication
# results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Added items adjudication
fhir:subDetail @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail>?; # Insurer added line items
}
# Additional items
<ExplanationOfBenefit.item.detail> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<PositiveInt>; # Product or service provided
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:category @<CodeableConcept>?; # Benefit classification
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is
# provided under
fhir:patientPaid @<Money>?; # Paid by the patient
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<Decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier
fhir:noteNumber @<OneOrMore_PositiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ExplanationOfBenefit.item.reviewOutcome>?; # Detail level adjudication results
fhir:adjudication @<OneOrMore_ExplanationOfBenefit.item.adjudication>?; # Detail level adjudication details
fhir:subDetail @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail>?; # Additional items
}
# Adjudication details
<ExplanationOfBenefit.item.adjudication> EXTENDS @<BackboneElement> CLOSED {
fhir:category @<CodeableConcept>; # Type of adjudication information
fhir:reason @<CodeableConcept>?; # Explanation of adjudication outcome
fhir:amount @<Money>?; # Monetary amount
fhir:quantity @<Quantity>?; # Non-monitary value
fhir:decisionDate @<DateTime>?; # When was adjudication performed
}
#---------------------- Cardinality Types (OneOrMore) -------------------
<OneOrMore_Identifier> CLOSED {
rdf:first @<Identifier> ;
rdf:rest [rdf:nil] OR @<OneOrMore_Identifier>
}
<OneOrMore_ExplanationOfBenefit.related> CLOSED {
rdf:first @<ExplanationOfBenefit.related> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.related>
}
<OneOrMore_ExplanationOfBenefit.event> CLOSED {
rdf:first @<ExplanationOfBenefit.event> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.event>
}
<OneOrMore_Reference_Encounter> CLOSED {
rdf:first @<Reference> AND {fhir:l
@<Encounter> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Encounter>
}
<OneOrMore_String> CLOSED {
rdf:first @<String> ;
rdf:rest [rdf:nil] OR @<OneOrMore_String>
}
<OneOrMore_Period> CLOSED {
rdf:first @<Period> ;
rdf:rest [rdf:nil] OR @<OneOrMore_Period>
}
<OneOrMore_ExplanationOfBenefit.careTeam> CLOSED {
rdf:first @<ExplanationOfBenefit.careTeam> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.careTeam>
}
<OneOrMore_ExplanationOfBenefit.supportingInfo> CLOSED {
rdf:first @<ExplanationOfBenefit.supportingInfo> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.supportingInfo>
}
<OneOrMore_ExplanationOfBenefit.diagnosis> CLOSED {
rdf:first @<ExplanationOfBenefit.diagnosis> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.diagnosis>
}
<OneOrMore_ExplanationOfBenefit.procedure> CLOSED {
rdf:first @<ExplanationOfBenefit.procedure> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.procedure>
}
<OneOrMore_ExplanationOfBenefit.insurance> CLOSED {
rdf:first @<ExplanationOfBenefit.insurance> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.insurance>
}
<OneOrMore_ExplanationOfBenefit.item> CLOSED {
rdf:first @<ExplanationOfBenefit.item> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item>
}
<OneOrMore_ExplanationOfBenefit.addItem> CLOSED {
rdf:first @<ExplanationOfBenefit.addItem> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem>
}
<OneOrMore_ExplanationOfBenefit.item.adjudication> CLOSED {
rdf:first @<ExplanationOfBenefit.item.adjudication> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.adjudication>
}
<OneOrMore_ExplanationOfBenefit.total> CLOSED {
rdf:first @<ExplanationOfBenefit.total> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.total>
}
<OneOrMore_ExplanationOfBenefit.processNote> CLOSED {
rdf:first @<ExplanationOfBenefit.processNote> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.processNote>
}
<OneOrMore_ExplanationOfBenefit.benefitBalance> CLOSED {
rdf:first @<ExplanationOfBenefit.benefitBalance> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.benefitBalance>
}
<OneOrMore_PositiveInt> CLOSED {
rdf:first @<PositiveInt> ;
rdf:rest [rdf:nil] OR @<OneOrMore_PositiveInt>
}
<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole> CLOSED {
rdf:first @<Reference> AND {fhir:l
@<Organization> OR
@<Practitioner> OR
@<PractitionerRole> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole>
}
<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription> CLOSED {
rdf:first @<Reference> AND {fhir:l
@<DeviceRequest> OR
@<MedicationRequest> OR
@<NutritionOrder> OR
@<ServiceRequest> OR
@<VisionPrescription> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_VisionPrescription>
}
<OneOrMore_CodeableConcept> CLOSED {
rdf:first @<CodeableConcept> ;
rdf:rest [rdf:nil] OR @<OneOrMore_CodeableConcept>
}
<OneOrMore_ExplanationOfBenefit.addItem.bodySite> CLOSED {
rdf:first @<ExplanationOfBenefit.addItem.bodySite> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.bodySite>
}
<OneOrMore_ExplanationOfBenefit.addItem.detail> CLOSED {
rdf:first @<ExplanationOfBenefit.addItem.detail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.detail>
}
<OneOrMore_Reference_Device> CLOSED {
rdf:first @<Reference> AND {fhir:l
@<Device> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Device>
}
<OneOrMore_ExplanationOfBenefit.benefitBalance.financial> CLOSED {
rdf:first @<ExplanationOfBenefit.benefitBalance.financial> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.benefitBalance.financial>
}
<OneOrMore_CodeableReference> CLOSED {
rdf:first @<CodeableReference> ;
rdf:rest [rdf:nil] OR @<OneOrMore_CodeableReference>
}
<OneOrMore_ExplanationOfBenefit.item.bodySite> CLOSED {
rdf:first @<ExplanationOfBenefit.item.bodySite> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.bodySite>
}
<OneOrMore_ExplanationOfBenefit.item.detail> CLOSED {
rdf:first @<ExplanationOfBenefit.item.detail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.detail>
}
<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail> CLOSED {
rdf:first @<ExplanationOfBenefit.addItem.detail.subDetail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.addItem.detail.subDetail>
}
<OneOrMore_ExplanationOfBenefit.item.detail.subDetail> CLOSED {
rdf:first @<ExplanationOfBenefit.item.detail.subDetail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ExplanationOfBenefit.item.detail.subDetail>
}
#---------------------- Value Sets ------------------------
# This value set includes Claim Processing Outcome codes.
fhirvs:claim-outcome ["queued" "complete" "error" "partial"]
# The purpose of the Claim: predetermination, preauthorization, claim.
fhirvs:claim-use ["claim" "preauthorization" "predetermination"]
# A code specifying the state of the resource instance.
fhirvs:explanationofbenefit-status ["active" "cancelled" "draft" "entered-in-error"]
Usage note: every effort has been made to ensure that the ShEx files are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot3 generated on Sun, Nov 9, 2025 23:54+0000.
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