CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 United States of America flag

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

Resource Profile: C4BB ExplanationOfBenefit Oral Basis

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis Version: 2.1.0
Standards status: Trial-use Computable Name: C4BBExplanationOfBenefitOralBasis

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. The basis profile does not have requirements for financial data.

This profile is defines the base requirements for an Oral 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).

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indicate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
  • .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
  • .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
  • .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
  • .item.productOrService: CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on an oral claim
  • .item.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the line
  • The line item primary body site (tooth or oral cavity) SHALL be specified in the .item.bodySite. Additional body sites (tooth or oral cavity) SHALL be specified in supportingInfo[additionalbodysite] repetitions with supportingInfo[additionalbodysite].sequence matching the line items .item.informationSequence
  • All Oral line item subsites (.item.subSite repetitions) apply to all the line item's associated tooth surfaces (item.bodySite and .supportingInfo[additionalbodysite] associated with the line item by referencing supportingInfo[additionalbodysite].sequence through .item.informationSequence)
  • ExplanationOfBenefit.adjudication elements may contain slices for both billing network status (billingnetworkstatus) or rendering network status (renderingnetworkstatus). ExplanationOfBenefit.adjudication and ExplanationOfBenefit.item.adjudication elements may contain slices for benefit payment status (benefitpaymentstatus). Each of these adjudication slices contain a reason code bound to very similar ValueSets that indicate network status. The billing or rendering network status indicates the general relationship (often a contract status) the provider has with the payer. The benefit payment status indicates how the service or product (either at the header or item level) is covered (in or out of network) in context to its provisioning. These values may be different across adjudication slices.
    An example of this is where an in network provider that has billed for a service that is not within the scope of the contract of service with the payer.
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... 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: oral
... provider 1..1 Reference(C4BB Practitioner | C4BB Organization) Party responsible for the claim
... careTeam C 0..* BackboneElement Care Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
.... 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:servicefacility S 0..1 BackboneElement Service facility
..... 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: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: orthodontics
..... code 0..1 CodeableConcept Type of information
..... Slices for timing[x] 0..1 date, Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
..... value[x] S 1..1 Quantity Total number of months for orthodontia
.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
..... 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: prosthesis
..... Slices for timing[x] 0..1 date, Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
..... sequence S 1..1 positiveInt Information instance identifier
..... 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: additionalbodysite
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
.... supportingInfo:missingtoothnumber S 0..* BackboneElement Missing tooth number
..... 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: missingtoothnumber
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
.... 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 0..* 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 Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] S 1..1 date, Period Date or dates of service or product delivery
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity Count of products or services
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... Slices for adjudication S 1..* 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..1 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: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: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
... Slices for adjudication S 2..* 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:renderingnetworkstatus S 1..1 BackboneElement Rendering 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: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... meta SΣ 1..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... lastUpdated SΣ 1..1 instant When the resource version last changed
ele-1: All FHIR elements must have a @value or children
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... 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.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
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.


ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
ele-1: All FHIR elements must have a @value or children
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: oral
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


ele-1: All FHIR elements must have a @value or children
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
ele-1: All FHIR elements must have a @value or children
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... provider SΣ 1..1 Reference(C4BB Practitioner | C4BB Organization) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... related S 0..* BackboneElement Prior or corollary claims
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... reference S 1..1 Identifier File or case reference
ele-1: All FHIR elements must have a @value or children
... payee SC 0..1 BackboneElement Recipient of benefits payable
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
ele-1: All FHIR elements must have a @value or children
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... careTeam SC 0..* BackboneElement Care Team members
ele-1: All FHIR elements must have a @value or children
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Order of care team
ele-1: All FHIR elements must have a @value or children
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
ele-1: All FHIR elements must have a @value or children
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
ele-1: All FHIR elements must have a @value or children
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: orthodontics
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.


ele-1: All FHIR elements must have a @value or children
..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
ele-1: All FHIR elements must have a @value or children
..... value[x] S 1..1 Quantity Total number of months for orthodontia
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: prosthesis
..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
ele-1: All FHIR elements must have a @value or children
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence S 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: additionalbodysite
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:missingtoothnumber S 0..* BackboneElement Missing tooth number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: missingtoothnumber
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
... diagnosis S 0..* BackboneElement Pertinent diagnosis information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Diagnosis instance identifier
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
... insurance SΣC 1..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
... item S 1..* BackboneElement Product or service provided
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence S 1..1 positiveInt Item instance identifier
ele-1: All FHIR elements must have a @value or children
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
ele-1: All FHIR elements must have a @value or children
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... serviced[x] S 1..1 Date or dates of service or product delivery
ele-1: All FHIR elements must have a @value or children
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... quantity 0..1 SimpleQuantity Count of products or services
ele-1: All FHIR elements must have a @value or children
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... noteNumber S 0..* positiveInt Applicable note numbers
ele-1: All FHIR elements must have a @value or children
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... adjudication:adjustmentreason S 0..1 BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
..... 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)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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
... Slices for adjudication S 2..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... adjudication:renderingnetworkstatus S 1..1 BackboneElement Rendering provider network status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... adjudication:benefitpaymentstatus S 1..* BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
... payment S 0..1 BackboneElement Payment Details
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
ele-1: All FHIR elements must have a @value or children
... processNote S 0..* BackboneElement Note concerning adjudication
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: oral
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.categoryextensiblePattern: orthodontics
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.categoryextensiblePattern: prosthesis
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.categoryextensiblePattern: additionalbodysite
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.categoryextensiblePattern: missingtoothnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by value:type
.... identifier: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
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 0..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.

..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
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)
.... 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: oral
..... 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 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... 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 ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 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 Practitioner | 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-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... 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 Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
... Slices for supportingInfo S 0..* 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:clmrecvddate S 0..1 BackboneElement Claim received date
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S 1..1 date When it occurred
..... 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:servicefacility S 0..1 BackboneElement Service facility
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... 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
..... 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
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: orthodontics
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
..... value[x] S 1..1 Quantity Total number of months for orthodontia
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: prosthesis
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
..... 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 S 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
...... 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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: additionalbodysite
....... 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
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
..... 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:missingtoothnumber S 0..* BackboneElement Missing tooth number
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: missingtoothnumber
....... 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
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
..... 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:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... 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)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... 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
..... 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
..... 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
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... 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)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... 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
..... 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
..... 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
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S 0..* BackboneElement Pertinent diagnosis information
.... 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 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 Professional And Non Clinician Diagnosis Type Value Set (required)
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..* BackboneElement Clinical procedures performed
.... 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 Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... 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
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... 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
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... 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 S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication: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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..1 BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ 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
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ 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
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... 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)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ 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
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... 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 Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... 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 Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... 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
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... 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
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... 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
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 2..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication: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
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:renderingnetworkstatus S 1..1 BackboneElement Rendering provider network status
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:benefitpaymentstatus S 1..* BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... 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
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... 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 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... 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
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... 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
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..* BackboneElement Benefit Summary
..... 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 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ExplanationOfBenefit.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ExplanationOfBenefit.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: oral
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:servicefacility.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:servicefacility.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:orthodontics.categoryextensiblePattern: orthodontics
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:orthodontics.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.categoryextensiblePattern: prosthesis
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:prosthesis.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:additionalbodysite.categoryextensiblePattern: additionalbodysite
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:missingtoothnumber.categoryextensiblePattern: missingtoothnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
from the FHIR Standard
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 9 elements(15 nested mandatory elements)
Must-Support: 47 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.timing[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

Differential View

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... 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: oral
... provider 1..1 Reference(C4BB Practitioner | C4BB Organization) Party responsible for the claim
... careTeam C 0..* BackboneElement Care Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
.... 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:servicefacility S 0..1 BackboneElement Service facility
..... 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: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: orthodontics
..... code 0..1 CodeableConcept Type of information
..... Slices for timing[x] 0..1 date, Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
..... value[x] S 1..1 Quantity Total number of months for orthodontia
.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
..... 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: prosthesis
..... Slices for timing[x] 0..1 date, Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
..... sequence S 1..1 positiveInt Information instance identifier
..... 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: additionalbodysite
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
.... supportingInfo:missingtoothnumber S 0..* BackboneElement Missing tooth number
..... 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: missingtoothnumber
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
.... 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 0..* 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 Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] S 1..1 date, Period Date or dates of service or product delivery
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity Count of products or services
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... Slices for adjudication S 1..* 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..1 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: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: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
... Slices for adjudication S 2..* 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:renderingnetworkstatus S 1..1 BackboneElement Rendering 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: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... meta SΣ 1..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... lastUpdated SΣ 1..1 instant When the resource version last changed
ele-1: All FHIR elements must have a @value or children
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... 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.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
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.


ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
ele-1: All FHIR elements must have a @value or children
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: oral
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


ele-1: All FHIR elements must have a @value or children
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
ele-1: All FHIR elements must have a @value or children
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... provider SΣ 1..1 Reference(C4BB Practitioner | C4BB Organization) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... related S 0..* BackboneElement Prior or corollary claims
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... reference S 1..1 Identifier File or case reference
ele-1: All FHIR elements must have a @value or children
... payee SC 0..1 BackboneElement Recipient of benefits payable
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
ele-1: All FHIR elements must have a @value or children
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... careTeam SC 0..* BackboneElement Care Team members
ele-1: All FHIR elements must have a @value or children
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Order of care team
ele-1: All FHIR elements must have a @value or children
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
ele-1: All FHIR elements must have a @value or children
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
ele-1: All FHIR elements must have a @value or children
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: orthodontics
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.


ele-1: All FHIR elements must have a @value or children
..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
ele-1: All FHIR elements must have a @value or children
..... value[x] S 1..1 Quantity Total number of months for orthodontia
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: prosthesis
..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
ele-1: All FHIR elements must have a @value or children
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence S 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: additionalbodysite
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:missingtoothnumber S 0..* BackboneElement Missing tooth number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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: missingtoothnumber
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
... diagnosis S 0..* BackboneElement Pertinent diagnosis information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Diagnosis instance identifier
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
... insurance SΣC 1..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
... item S 1..* BackboneElement Product or service provided
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence S 1..1 positiveInt Item instance identifier
ele-1: All FHIR elements must have a @value or children
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
ele-1: All FHIR elements must have a @value or children
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... serviced[x] S 1..1 Date or dates of service or product delivery
ele-1: All FHIR elements must have a @value or children
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... quantity 0..1 SimpleQuantity Count of products or services
ele-1: All FHIR elements must have a @value or children
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... noteNumber S 0..* positiveInt Applicable note numbers
ele-1: All FHIR elements must have a @value or children
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... adjudication:adjustmentreason S 0..1 BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
..... 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)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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
... Slices for adjudication S 2..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... adjudication:renderingnetworkstatus S 1..1 BackboneElement Rendering provider network status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... adjudication:benefitpaymentstatus S 1..* BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
... payment S 0..1 BackboneElement Payment Details
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
ele-1: All FHIR elements must have a @value or children
... processNote S 0..* BackboneElement Note concerning adjudication
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: oral
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.categoryextensiblePattern: orthodontics
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.categoryextensiblePattern: prosthesis
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.categoryextensiblePattern: additionalbodysite
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.categoryextensiblePattern: missingtoothnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by value:type
.... identifier: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
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 0..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.

..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
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)
.... 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: oral
..... 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 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... 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 ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 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 Practitioner | 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-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... 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 Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
... Slices for supportingInfo S 0..* 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:clmrecvddate S 0..1 BackboneElement Claim received date
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S 1..1 date When it occurred
..... 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:servicefacility S 0..1 BackboneElement Service facility
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... 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
..... 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
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:orthodontics S 0..1 BackboneElement Orthodontics treatment indicator
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: orthodontics
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Orthodontics appliance application date (200)
..... value[x] S 1..1 Quantity Total number of months for orthodontia
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:prosthesis S 0..1 BackboneElement Prosthesis
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: prosthesis
....... 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
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 0..1 When it occurred
Slice: Unordered, Open by type:$this
...... timingDate date
...... timingPeriod Period
...... timing[x]:timingDate 0..1 date Date of prior prosthesis replacement (203)
..... value[x] S 1..1 boolean Prosthesis replacement indicator (202
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:additionalbodysite S 0..* BackboneElement Additional tooth number or oral cavity code
..... 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 S 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
...... 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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: additionalbodysite
....... 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
..... code S 1..1 CodeableConcept Type of information
Binding: Oral Body Site Value Set (required)
..... 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:missingtoothnumber S 0..* BackboneElement Missing tooth number
..... 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 (extensible)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: missingtoothnumber
....... 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
..... code S 1..1 CodeableConcept Type of information
Binding: American Dental Association Universal Numbering Value Set (required)
..... 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:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... 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)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... 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
..... 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
..... 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
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... 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)
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/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... 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
..... 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
..... 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
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S 0..* BackboneElement Pertinent diagnosis information
.... 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 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 Professional And Non Clinician Diagnosis Type Value Set (required)
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..* BackboneElement Clinical procedures performed
.... 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 Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... 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
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... 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
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... 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 S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence S 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite S 0..1 CodeableConcept First tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..* CodeableConcept Tooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication: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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..1 BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ 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
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ 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
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... 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)
...... 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
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ 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
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... 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 Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... 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 Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... 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
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... 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
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... 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
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 2..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication: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
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:renderingnetworkstatus S 1..1 BackboneElement Rendering provider network status
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:benefitpaymentstatus S 1..* BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... 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
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... 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
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... 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
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... 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 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... 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
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... 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
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..* BackboneElement Benefit Summary
..... 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 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ExplanationOfBenefit.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ExplanationOfBenefit.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: oral
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:servicefacility.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:servicefacility.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:orthodontics.categoryextensiblePattern: orthodontics
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:orthodontics.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:orthodontics.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.categoryextensiblePattern: prosthesis
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:prosthesis.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:prosthesis.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:additionalbodysite.categoryextensiblePattern: additionalbodysite
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.supportingInfo:additionalbodysite.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:missingtoothnumber.categoryextensiblePattern: missingtoothnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
http://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem
from this IG
ExplanationOfBenefit.supportingInfo:missingtoothnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
from the FHIR Standard
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
http://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
http://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite
from this IG
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence
: item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty()

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 9 elements(15 nested mandatory elements)
Must-Support: 47 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.timing[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

 

Other representations of profile: CSV, Excel, Schematron