CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis | Version: 2.1.0 | |||
Standards status: Trial-use | Computable Name: C4BBExplanationOfBenefitInpatientInstitutionalBasis |
The basis profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services. The basis profile does not have requirements for financial data.
This profile is defines the base requirements for an Inpatient Institutional ExplanationOfBenefit. All of the requirements are an exact subset of the original profile from earlier versions with only the financial data element requirements removed in order to address the use case of sharing Non-Financial Claims Data that enables other FHIR Implementation Guides to support communication of ExplanationOfBenefit data without financial data. These profiles are not expected to be implemented directly within the context of the consumer directed data exchange use case defined by this guide, but rather from within the context in which external guides may define (e.g. Provider Access API of PDEX).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from C4BBExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. |
identifier | S | 1..* | Identifier | Business Identifier for the resource |
type | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
subType | S | 1..1 | CodeableConcept | More granular claim type Binding: C4BB Institutional Claim SubType Value Set (required) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: inpatient | |
billablePeriod | ||||
end | S | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
created | S | 1..1 | dateTime | Response creation date |
provider | 1..1 | Reference(C4BB Organization) | Party responsible for the claim | |
careTeam | C | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization |
role | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Institutional Care Team Role Value Set (required) | |
Slices for supportingInfo | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category | |
supportingInfo:admissionperiod | S | 1..1 | BackboneElement | Admission Period |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionperiod | |
Slices for timing[x] | 1..1 | Period | When it occurred Slice: Unordered, Open by type:$this | |
timing[x]:timingPeriod | S | 1..1 | Period | When it occurred |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | S | 1..1 | date | When it occurred |
supportingInfo:typeofbill | S | 0..1 | BackboneElement | Type of bill |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill Codes Value Set (required) |
supportingInfo:pointoforigin | S | 0..1 | BackboneElement | Point of origin for admission |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pointoforigin | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Point Of Origin Value Set (required) |
supportingInfo:admtype | S | 0..1 | BackboneElement | Admission type |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Priority (Type) of Admission or Visit Value Set (required) |
supportingInfo:discharge-status | S | 0..1 | BackboneElement | Discharge status |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status Codes Value Set (required) |
supportingInfo:drg | S | 0..1 | BackboneElement | Diagnosis Related Group |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
code | S | 1..1 | CodeableConcept | Type of information Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible) |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required) |
onAdmission | S | 0..1 | CodeableConcept | Present on admission Binding: CMS Present On Admission Indicator Codes Value Set (required) |
procedure | S | 0..* | BackboneElement | Clinical procedures performed |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | S | 1..1 | CodeableConcept | Category of Procedure Binding: C4BB Claim Procedure Type Value Set (required) |
date | S | 0..1 | dateTime | When the procedure was performed |
procedure[x] | S | 1..1 | CodeableConcept | Specific clinical procedure Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required) |
item | ||||
revenue | S | 1..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Codes Value Set (required) |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required) |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
Slices for adjudication | S | 0..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) | |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required) |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
Slices for adjudication | S | 1..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) |
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing provider network status |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required) |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required) |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required) |
payment | ||||
date | S | 0..1 | date | Expected date of payment |
processNote | ||||
text | S | 0..1 | string | Note explanatory text |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.subType | required | Pattern: inpatienthttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType from this IG | |
ExplanationOfBenefit.careTeam.role | required | C4BBClaimInstitutionalCareTeamRolehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole from this IG | |
ExplanationOfBenefit.supportingInfo:typeofbill.code | required | AHANUBCTypeOfBillhttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill from this IG | |
ExplanationOfBenefit.supportingInfo:pointoforigin.code | required | AHANUBCPointOfOriginForAdmissionOrVisithttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit from this IG | |
ExplanationOfBenefit.supportingInfo:admtype.code | required | AHANUBCPriorityTypeOfAdmissionOrVisithttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit from this IG | |
ExplanationOfBenefit.supportingInfo:discharge-status.code | required | AHANUBCPatientDischargeStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus from this IG | |
ExplanationOfBenefit.supportingInfo:drg.code | extensible | CMSMS3MAPAPRDRGhttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG from this IG | |
ExplanationOfBenefit.diagnosis.diagnosis[x] | required | CDCICD910CMDiagnosisCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes from this IG | |
ExplanationOfBenefit.diagnosis.type | required | C4BBClaimInpatientInstitutionalDiagnosisTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType from this IG | |
ExplanationOfBenefit.diagnosis.onAdmission | required | CMSPresentOnAdmissionIndicatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSPresentOnAdmissionIndicator from this IG | |
ExplanationOfBenefit.procedure.type | required | C4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType from this IG | |
ExplanationOfBenefit.procedure.procedure[x] | required | CMSICD910PCSProcedureCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes from this IG | |
ExplanationOfBenefit.item.revenue | required | AHANUBCRevenueCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes from this IG | |
ExplanationOfBenefit.item.productOrService | required | C4BBEOBInstitutionalProcedureCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSModifiershttp://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG | |
ExplanationOfBenefit.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-inst-careTeam-organization | error | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to an organization : ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) ) | |
EOB-inst-careTeam-practitioner | error | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) ) | |
EOB-inst-pointoforigin | error | ExplanationOfBenefit | Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. : (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. |
meta | SΣ | 1..1 | Meta | Metadata about the resource |
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed |
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
Slices for identifier | S | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type |
identifier:uniqueclaimid | S | 1..1 | Identifier | Unique Claim Identifier |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
value | SΣ | 1..1 | string | Unique Claim Identifier Example General: 123456 |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
subType | S | 1..1 | CodeableConcept | More granular claim type Binding: C4BB Institutional Claim SubType Value Set (required) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: inpatient | |
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim |
patient | SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | SΣ | 1..1 | Period | Relevant time frame for the claim |
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary |
end | SΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
created | SΣ | 1..1 | dateTime | Response creation date |
insurer | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for the claim |
related | S | 0..* | BackboneElement | Prior or corollary claims |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) |
reference | S | 1..1 | Identifier | File or case reference |
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) |
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference |
outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
careTeam | SC | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization |
role | S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Institutional Care Team Role Value Set (required) |
Slices for supportingInfo | S | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category |
supportingInfo:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |
supportingInfo:admissionperiod | S | 1..1 | BackboneElement | Admission Period |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionperiod | |
Slices for timing[x] | 1..1 | Period | When it occurred Slice: Unordered, Closed by type:$this | |
timing[x]:timingPeriod | S | 1..1 | Period | When it occurred |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | S | 1..1 | date | When it occurred |
supportingInfo:typeofbill | S | 0..1 | BackboneElement | Type of bill |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Type of Bill Codes Value Set (required) |
supportingInfo:pointoforigin | S | 0..1 | BackboneElement | Point of origin for admission |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pointoforigin | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Point Of Origin Value Set (required) |
supportingInfo:admtype | S | 0..1 | BackboneElement | Admission type |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Priority (Type) of Admission or Visit Value Set (required) |
supportingInfo:discharge-status | S | 0..1 | BackboneElement | Discharge status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
code | S | 1..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status Codes Value Set (required) |
supportingInfo:drg | S | 0..1 | BackboneElement | Diagnosis Related Group |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
code | S | 1..1 | CodeableConcept | Type of information Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible) |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
diagnosis | S | 1..* | BackboneElement | Pertinent diagnosis information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required) |
onAdmission | S | 0..1 | CodeableConcept | Present on admission Binding: CMS Present On Admission Indicator Codes Value Set (required) |
procedure | S | 0..* | BackboneElement | Clinical procedures performed |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | S | 1..1 | CodeableConcept | Category of Procedure Binding: C4BB Claim Procedure Type Value Set (required) |
date | S | 0..1 | dateTime | When the procedure was performed |
procedure[x] | S | 1..1 | CodeableConcept | Specific clinical procedure Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required) |
insurance | SΣC | 1..* | BackboneElement | Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | SΣ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information |
item | S | 1..* | BackboneElement | Product or service provided |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | S | 1..1 | positiveInt | Item instance identifier |
revenue | S | 1..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Codes Value Set (required) |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required) |
quantity | S | 0..1 | SimpleQuantity | Count of products or services |
noteNumber | S | 0..* | positiveInt | Applicable note numbers |
Slices for adjudication | S | 0..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required) |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
Slices for adjudication | S | 1..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category |
adjudication:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) |
adjudication:billingnetworkstatus | S | 0..1 | BackboneElement | Billing provider network status |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required) |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required) |
adjudication:adjustmentreason | S | 0..* | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required) |
payment | S | 0..1 | BackboneElement | Payment Details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required) |
date | S | 0..1 | date | Expected date of payment |
processNote | S | 0..* | BackboneElement | Note concerning adjudication |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
text | S | 0..1 | string | Note explanatory text |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uchttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | required | Pattern: institutionalhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.subType | required | Pattern: inpatienthttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType from this IG | |
ExplanationOfBenefit.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes from this IG | |
ExplanationOfBenefit.payee.type | required | C4BBPayeeTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType from this IG | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.careTeam.role | required | C4BBClaimInstitutionalCareTeamRolehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole from this IG | |
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:admissionperiod.category | extensible | Pattern: admissionperiodhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:clmrecvddate.category | extensible | Pattern: clmrecvddatehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:typeofbill.category | extensible | Pattern: typeofbillhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:typeofbill.code | required | AHANUBCTypeOfBillhttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill from this IG | |
ExplanationOfBenefit.supportingInfo:pointoforigin.category | extensible | Pattern: pointoforiginhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:pointoforigin.code | required | AHANUBCPointOfOriginForAdmissionOrVisithttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit from this IG | |
ExplanationOfBenefit.supportingInfo:admtype.category | extensible | Pattern: admtypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:admtype.code | required | AHANUBCPriorityTypeOfAdmissionOrVisithttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit from this IG | |
ExplanationOfBenefit.supportingInfo:discharge-status.category | extensible | Pattern: discharge-statushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:discharge-status.code | required | AHANUBCPatientDischargeStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus from this IG | |
ExplanationOfBenefit.supportingInfo:drg.category | extensible | Pattern: drghttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:drg.code | extensible | CMSMS3MAPAPRDRGhttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG from this IG | |
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category | extensible | Pattern: medicalrecordnumberhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:patientaccountnumber.category | extensible | Pattern: patientaccountnumberhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.diagnosis.diagnosis[x] | required | CDCICD910CMDiagnosisCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes from this IG | |
ExplanationOfBenefit.diagnosis.type | required | C4BBClaimInpatientInstitutionalDiagnosisTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType from this IG | |
ExplanationOfBenefit.diagnosis.onAdmission | required | CMSPresentOnAdmissionIndicatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSPresentOnAdmissionIndicator from this IG | |
ExplanationOfBenefit.procedure.type | required | C4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType from this IG | |
ExplanationOfBenefit.procedure.procedure[x] | required | CMSICD910PCSProcedureCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes from this IG | |
ExplanationOfBenefit.item.revenue | required | AHANUBCRevenueCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes from this IG | |
ExplanationOfBenefit.item.productOrService | required | C4BBEOBInstitutionalProcedureCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes from this IG | |
ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSModifiershttp://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG | |
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunitshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG | |
ExplanationOfBenefit.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG | |
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-inst-careTeam-organization | error | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to an organization : ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) ) | |
EOB-inst-careTeam-practitioner | error | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) ) | |
EOB-inst-pointoforigin | error | ExplanationOfBenefit | Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. : (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | SΣ | 1..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | S | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | ||||
identifier:uniqueclaimid | S | 1..1 | Identifier | Unique Claim Identifier | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | SΣ | 1..1 | string | Unique Claim Identifier Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subType | S | 1..1 | CodeableConcept | More granular claim type Binding: C4BB Institutional Claim SubType Value Set (required) Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: inpatient | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim | ||||
patient | SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services | ||||
billablePeriod | SΣ | 1..1 | Period | Relevant time frame for the claim | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
end | SΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
created | SΣ | 1..1 | dateTime | Response creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement | ||||
provider | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
related | S | 0..* | BackboneElement | Prior or corollary claims | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) | ||||
reference | S | 1..1 | Identifier | File or case reference | ||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) | ||||
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference | ||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
facility | 0..1 | Reference(Location) | Servicing Facility | |||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
careTeam | SC | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | ||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Institutional Care Team Role Value Set (required) | ||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
Slices for supportingInfo | S | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category | ||||
supportingInfo:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |||||
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Resource) | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
supportingInfo:admissionperiod | S | 1..1 | BackboneElement | Admission Period | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set ( |