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
Page standards status: Trial-use |
Definitions for the C4BB-ExplanationOfBenefit-Outpatient-Institutional resource profile.
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |
Invariants | EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient EOB: meta.profile with canonical and major.minor. version required. (meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.1')) )EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both ( adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() ) |
2. ExplanationOfBenefit.item | |
Invariants | adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ((adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()) ) |
4. ExplanationOfBenefit.item.adjudication:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Short | Line level adjudication type and amount |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) |
Control | 0..* |
Must Support | true |
6. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | |
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
8. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount | |
Control | 1..? |
Must Support | true |
10. ExplanationOfBenefit.adjudication:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Short | Claim level adjudication type and amount |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) |
Control | 0..* |
Must Support | true |
12. ExplanationOfBenefit.adjudication:adjudicationamounttype.category | |
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
14. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount | |
Control | 1..? |
Must Support | true |
16. ExplanationOfBenefit.total | |
Control | 1..? |
Must Support | true |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.total . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
18. ExplanationOfBenefit.total.category | |
Binding | Unless not suitable, these codes SHALL be taken from C4BB Total Category Discriminator Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator ) |
Must Support | true |
20. ExplanationOfBenefit.total.amount | |
Comments | Total amount for each category (i.e., submitted, allowed, etc.) (148) |
22. ExplanationOfBenefit.total:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Short | Total adjudication type and amount |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) |
Control | 1..* |
Must Support | true |
24. ExplanationOfBenefit.total:adjudicationamounttype.category | |
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
26. ExplanationOfBenefit.total:adjudicationamounttype.amount | |
Must Support | true |
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided. |
Short | Explanation of Benefit resource |
Control | 0..* |
Is Modifier | false |
Summary | false |
Alternate Names | EOB |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) 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 (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. ( (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not() )EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient EOB: meta.profile with canonical and major.minor. version required. ( meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.1')) )EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both ( adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() ) |
2. ExplanationOfBenefit.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
Short | Metadata about the resource |
Control | 10..1 |
Type | Meta |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. ExplanationOfBenefit.meta.lastUpdated | |
Definition | When the resource last changed - e.g. when the version changed. |
Short | When the resource version last changed |
Comments | Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. |
Control | 10..1 |
Type | instant |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
6. ExplanationOfBenefit.meta.profile | |
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. |
Short | Profiles this resource claims to conform to |
Comments | 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. CPCDS data element (190) It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. |
Control | 10..* |
Type | canonical(StructureDefinition) |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
8. ExplanationOfBenefit.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
10. ExplanationOfBenefit.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
12. ExplanationOfBenefit.identifier | |
Definition | A unique identifier assigned to this explanation of benefit. |
Short | Business Identifier for the resource |
Comments | Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35) |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 10..* |
Type | Identifier |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Allows EOBs to be distinguished and referenced. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
14. ExplanationOfBenefit.identifier:uniqueclaimid | |
Slice Name | uniqueclaimid |
Definition | A unique identifier assigned to this explanation of benefit. |
Short | Unique Claim IdentifierBusiness Identifier for the resource |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 10..1* |
Type | Identifier |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Allows EOBs to be distinguished and referenced. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. ExplanationOfBenefit.identifier:uniqueclaimid.use | |
Definition | The purpose of this identifier. |
Short | usual | official | temp | secondary | old (If known) |
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
Control | 0..1 |
Binding | The codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 )Identifies the purpose for this identifier, if known . |
Type | code |
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. ExplanationOfBenefit.identifier:uniqueclaimid.type | |
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. |
Short | Description of identifier |
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. |
Control | 10..1 |
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type (extensible to http://hl7.org/fhir/ValueSet/identifier-type )A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Allows users to make use of identifiers when the identifier system is not known. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. ExplanationOfBenefit.identifier:uniqueclaimid.value | |
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. |
Short | Unique Claim IdentifierThe value that is unique |
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. |
Control | 10..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Example | <br/><b>General</b>:123456 |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. ExplanationOfBenefit.status | |
Definition | The status of the resource instance. |
Short | active | cancelled | draft | entered-in-error |
Comments | Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 )A code specifying the state of the resource instance. |
Type | code |
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
24. ExplanationOfBenefit.type | |
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. |
Short | Category or discipline |
Comments | Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements. |
Control | 1..1 |
Binding | The codes SHALL be taken from Unless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type (required to http://hl7.org/fhir/ValueSet/claim-type ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. ExplanationOfBenefit.subType | |
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. |
Short | More granular claim type |
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Institutional Claim SubType Value Sethttp://hl7.org/fhir/ValueSet/claim-subtype (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
28. ExplanationOfBenefit.use | |
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. |
Short | claim | preauthorization | predetermination |
Comments | Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations |
Control | 1..1 |
Binding | The codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 )Complete, proposed, exploratory, other. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | This element is required to understand the nature of the request for adjudication. |
Pattern Value | claim |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
30. ExplanationOfBenefit.patient | |
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. |
Short | The recipient of the products and services |
Comments | Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier |
Control | 1..1 |
Type | Reference(C4BB Patient, Patient) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
32. ExplanationOfBenefit.billablePeriod | |
Definition | The period for which charges are being submitted. |
Short | Relevant time frame for the claim |
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. |
Control | 10..1 |
Type | Period |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
34. ExplanationOfBenefit.billablePeriod.start | |
Definition | The start of the period. The boundary is inclusive. |
Short | Starting time with inclusive boundary |
Comments | The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177) If the low element is missing, the meaning is that the low boundary is not known. |
Control | 10..1 This element is affected by the following invariants: per-1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
36. ExplanationOfBenefit.created | |
Definition | The date this resource was created. |
Short | Response creation date |
Comments | Date the claim was adjudicated (179) This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date. |
Control | 1..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
38. ExplanationOfBenefit.insurer | |
Definition | The party responsible for authorization, adjudication and reimbursement. |
Short | Party responsible for reimbursement |
Comments | Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider |
Control | 1..1 |
Type | Reference(C4BB Organization, Organization) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
40. ExplanationOfBenefit.provider | |
Definition | The provider which is responsible for the claim, predetermination or preauthorization. |
Short | Party responsible for the claim |
Comments | The identifier assigned to the Billing Provider. (94) Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. |
Control | 1..1 |
Type | Reference(C4BB Organization, Practitioner, PractitionerRole, Organization) |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
42. ExplanationOfBenefit.related | |
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. |
Short | Prior or corollary claims |
Comments | If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112) For example, for the original treatment and follow-up exams. |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
44. ExplanationOfBenefit.related.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
46. ExplanationOfBenefit.related.relationship | |
Definition | A code to convey how the claims are related. |
Short | How the reference claim is related |
Comments | For example, prior claim or umbrella. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Related Claim Relationship Codes Value Sethttp://hl7.org/fhir/ValueSet/related-claim-relationship (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers need a declaration of the type of relationship. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
48. ExplanationOfBenefit.related.reference | |
Definition | An alternate organizational reference to the case or file to which this particular claim pertains. |
Short | File or case reference |
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number. |
Control | 10..1 |
Type | Identifier |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
50. ExplanationOfBenefit.payee | |
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy. |
Short | Recipient of benefits payable |
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead. |
Control | 0..1 |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required ( type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists() ) |
52. ExplanationOfBenefit.payee.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
54. ExplanationOfBenefit.payee.type | |
Definition | Type of Party to be reimbursed: Subscriber, provider, other. |
Short | Category of recipient |
Comments | Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120) |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Payee Type Value Sethttp://hl7.org/fhir/ValueSet/payeetype (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
56. ExplanationOfBenefit.payee.party | |
Definition | Reference to the individual or organization to whom any payment will be made. |
Short | Recipient reference |
Comments | Recipient reference (121) Not required if the payee is 'subscriber' or 'provider'. |
Control | 0..1 |
Type | Reference(C4BB Organization, C4BB Patient, C4BB Practitioner, C4BB RelatedPerson, Practitioner, PractitionerRole, Organization, Patient, RelatedPerson) |
Is Modifier | false |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | false |
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
58. ExplanationOfBenefit.outcome | |
Definition | The outcome of the claim, predetermination, or preauthorization processing. |
Short | queued | complete | error | partial |
Comments | Expected value is complete The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). |
Control | 1..1 |
Binding | The codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 )The result of the claim processing. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | To advise the requestor of an overall processing outcome. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
60. ExplanationOfBenefit.careTeam | |
Definition | The members of the team who provided the products and services. |
Short | Care Team members |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Common to identify the responsible and supporting practitioners. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner ( (
role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies
provider.all(resolve() is Practitioner)
) )EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization ( (
role.where(coding.where(code in ('rendering' )).exists()).exists() implies
provider.all(resolve() is Organization)
) )EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set ( where(role.where(coding.code in ('rendering')).exists().not() or qualification.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066')).exists() ) |
62. ExplanationOfBenefit.careTeam.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
64. ExplanationOfBenefit.careTeam.sequence | |
Definition | A number to uniquely identify care team entries. |
Short | Order of care team |
Comments | careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
66. ExplanationOfBenefit.careTeam.provider | |
Definition | Member of the team who provided the product or service. |
Short | Practitioner or organization |
Comments | The identifier assigned to the care team. (varies depending on the profile) |
Control | 1..1 |
Type | Reference(C4BB Organization, C4BB Practitioner, Practitioner, PractitionerRole, Organization) |
Is Modifier | false |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | false |
Requirements | Often a regulatory requirement to specify the responsible provider. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
68. ExplanationOfBenefit.careTeam.role | |
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. |
Short | Function within the team |
Comments | The functional role of a provider on a claim. (165) Role might not be required when there is only a single provider listed. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Claim Institutional Care Team Role Value Sethttp://hl7.org/fhir/ValueSet/claim-careteamrole (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
70. ExplanationOfBenefit.supportingInfo | |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Supporting information |
Comments | Defines data elements not available in the base EOB resource Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
72. ExplanationOfBenefit.supportingInfo.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
74. ExplanationOfBenefit.supportingInfo.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
76. ExplanationOfBenefit.supportingInfo.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
78. ExplanationOfBenefit.supportingInfo:clmrecvddate | |
Slice Name | clmrecvddate |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Claim received dateSupporting information |
Comments | The date the claim was received by the payer (88) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
80. ExplanationOfBenefit.supportingInfo:clmrecvddate.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
82. ExplanationOfBenefit.supportingInfo:clmrecvddate.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
84. ExplanationOfBenefit.supportingInfo:clmrecvddate.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
86. ExplanationOfBenefit.supportingInfo:clmrecvddate.timing[x] | |
Definition | The date when or period to which this information refers. |
Short | When it occurred |
Control | 10..1 |
Type | date, Period |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
88. ExplanationOfBenefit.supportingInfo:typeofbill | |
Slice Name | typeofbill |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Type of billSupporting information |
Comments | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
90. ExplanationOfBenefit.supportingInfo:typeofbill.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
92. ExplanationOfBenefit.supportingInfo:typeofbill.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
94. ExplanationOfBenefit.supportingInfo:typeofbill.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
96. ExplanationOfBenefit.supportingInfo:typeofbill.code | |
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. |
Short | Type of information |
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see NUBC Type of Bill Codes Value Sethttp://hl7.org/fhir/ValueSet/claim-exception (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to identify the kind of additional information. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
98. ExplanationOfBenefit.supportingInfo:pointoforigin | |
Slice Name | pointoforigin |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Point of origin for admission or visitSupporting information |
Comments | Identifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
100. ExplanationOfBenefit.supportingInfo:pointoforigin.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
102. ExplanationOfBenefit.supportingInfo:pointoforigin.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
104. ExplanationOfBenefit.supportingInfo:pointoforigin.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
106. ExplanationOfBenefit.supportingInfo:pointoforigin.code | |
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. |
Short | Type of information |
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see NUBC Point Of Origin Value Sethttp://hl7.org/fhir/ValueSet/claim-exception (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to identify the kind of additional information. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
108. ExplanationOfBenefit.supportingInfo:admtype | |
Slice Name | admtype |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Admission typeSupporting information |
Comments | Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. (14) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
110. ExplanationOfBenefit.supportingInfo:admtype.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
112. ExplanationOfBenefit.supportingInfo:admtype.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
114. ExplanationOfBenefit.supportingInfo:admtype.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
116. ExplanationOfBenefit.supportingInfo:admtype.code | |
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. |
Short | Type of information |
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see NUBC Priority (Type) of Admission or Visit Value Sethttp://hl7.org/fhir/ValueSet/claim-exception (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to identify the kind of additional information. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
118. ExplanationOfBenefit.supportingInfo:discharge-status | |
Slice Name | discharge-status |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Discharge statusSupporting information |
Comments | Patient’s status as of the discharge date for a facility stay. Information located on UB04. (Form Locator 17). (117) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
120. ExplanationOfBenefit.supportingInfo:discharge-status.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
122. ExplanationOfBenefit.supportingInfo:discharge-status.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
124. ExplanationOfBenefit.supportingInfo:discharge-status.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
126. ExplanationOfBenefit.supportingInfo:discharge-status.code | |
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. |
Short | Type of information |
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see NUBC Patient Discharge Status Codes Value Sethttp://hl7.org/fhir/ValueSet/claim-exception (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required to identify the kind of additional information. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
128. ExplanationOfBenefit.supportingInfo:medicalrecordnumber | |
Slice Name | medicalrecordnumber |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Medical record numberSupporting information |
Comments | Provider submitted medical record number that can be included on the claim. (109) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
130. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
132. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
134. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
136. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x] | |
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. |
Short | Data to be provided |
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. |
Control | 10..1 |
Type | string, boolean, Reference(Resource), Quantity, Attachment |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | To convey the data content to be provided when the information is more than a simple code or period. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x] . The slices areUnordered and Closed, and can be differentiated using the following discriminators: |
138. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]:valueString | |
Slice Name | valueString |
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. |
Short | Data to be provided |
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. |
Control | 10..1 |
Type | string, boolean, Reference(Resource), Quantity, Attachment |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | To convey the data content to be provided when the information is more than a simple code or period. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
140. ExplanationOfBenefit.supportingInfo:patientaccountnumber | |
Slice Name | patientaccountnumber |
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. |
Short | Patient account numberSupporting information |
Comments | Provider assigned patient account number that can be included on the claim. (109) Often there are multiple jurisdiction specific valuesets which are required. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
142. ExplanationOfBenefit.supportingInfo:patientaccountnumber.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
144. ExplanationOfBenefit.supportingInfo:patientaccountnumber.sequence | |
Definition | A number to uniquely identify supporting information entries. |
Short | Information instance identifier |
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
146. ExplanationOfBenefit.supportingInfo:patientaccountnumber.category | |
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. |
Short | Classification of the supplied information |
Comments | This may contain a category for the local bill type codes. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB SupportingInfo Type Value Sethttp://hl7.org/fhir/ValueSet/claim-informationcategory (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
148. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x] | |
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. |
Short | Data to be provided |
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. |
Control | 10..1 |
Type | string, boolean, Reference(Resource), Quantity, Attachment |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | To convey the data content to be provided when the information is more than a simple code or period. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x] . The slices areUnordered and Closed, and can be differentiated using the following discriminators: |
150. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]:valueString | |
Slice Name | valueString |
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. |
Short | Data to be provided |
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. |
Control | 10..1 |
Type | string, boolean, Reference(Resource), Quantity, Attachment |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | To convey the data content to be provided when the information is more than a simple code or period. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
152. ExplanationOfBenefit.diagnosis | |
Definition | Information about diagnoses relevant to the claim items. |
Short | Pertinent diagnosis information |
Comments | Diagnosis codes describe an individual's disease or medical condition. (6, 7, 8, 21, 22, 23, 30) |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Requirements | Required for the adjudication by provided context for the services and product listed. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
154. ExplanationOfBenefit.diagnosis.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
156. ExplanationOfBenefit.diagnosis.sequence | |
Definition | A number to uniquely identify diagnosis entries. |
Short | Diagnosis instance identifier |
Comments | 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 are presented in list order to their expected importance: primary, secondary, etc. |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
158. ExplanationOfBenefit.diagnosis.diagnosis[x] | |
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition. |
Short | Nature of illness or problem |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Sethttp://hl7.org/fhir/ValueSet/icd-10 (required to http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes ) |
Type | CodeableConcept, Reference(Condition) |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Provides health context for the evaluation of the products and/or services. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
160. ExplanationOfBenefit.diagnosis.type | |
Definition | When the condition was observed or the relative ranking. |
Short | Timing or nature of the diagnosis |
Comments | Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit. (21, 22, 23) For example: admitting, primary, secondary, discharge. |
Control | 10..1* |
Binding | The codes SHALL be taken from For example codes, see C4BB Claim Outpatient Institutional Diagnosis Type Value Sethttp://hl7.org/fhir/ValueSet/ex-diagnosistype (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimOutpatientInstitutionalDiagnosisType ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
162. ExplanationOfBenefit.insurance | |
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim. |
Short | Patient insurance information |
Comments | Identity of the payers responsible for the claim. (2, 141). All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True' All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. |
Control | 1..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | At least one insurer is required for a claim to be a claim. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) EOB-insurance-focal: EOB.insurance: at most one with focal = true ( select (focal = true).count() < 2 ) |
164. ExplanationOfBenefit.insurance.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
166. ExplanationOfBenefit.insurance.focal | |
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. |
Short | Coverage to be used for adjudication |
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True' A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. |
Control | 1..1 |
Type | boolean |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | To identify which coverage in the list is being used to adjudicate this claim. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
168. ExplanationOfBenefit.insurance.coverage | |
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. |
Short | Insurance information |
Comments | Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier] |
Control | 1..1 |
Type | Reference(C4BB Coverage, Coverage) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
170. ExplanationOfBenefit.item | |
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. |
Short | Product or service provided |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The items to be processed for adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ( (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()) ) |
172. ExplanationOfBenefit.item.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
174. ExplanationOfBenefit.item.sequence | |
Definition | A number to uniquely identify item entries. |
Short | Item instance identifier |
Comments | Line identification number that represents the number assigned in a source system for identification and processing. (36) |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
176. ExplanationOfBenefit.item.revenue | |
Definition | The type of revenue or cost center providing the product and/or service. |
Short | Revenue or cost center code |
Comments | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86) |
Control | 0..1 |
Binding | The codes SHALL be taken from For example codes, see NUBC Revenue Codes Value Sethttp://hl7.org/fhir/ValueSet/ex-revenue-center (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed in the processing of institutional claims. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
178. ExplanationOfBenefit.item.productOrService | |
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. |
Short | Billing, service, product, or drug code |
Comments | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40) If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Sethttp://hl7.org/fhir/ValueSet/service-uscls (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Necessary to state what was provided or done. |
Alternate Names | Drug Code, Bill Code, Service Code |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
180. ExplanationOfBenefit.item.modifier | |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Short | Product or service billing modifiers |
Comments | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41) For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. |
Control | 0..* |
Binding | The codes SHALL be taken from For example codes, see Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Sethttp://hl7.org/fhir/ValueSet/claim-modifiers (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
182. ExplanationOfBenefit.item.serviced[x] | |
Definition | The date or dates when the service or product was supplied, performed or completed. |
Short | Date or dates of service or product delivery |
Control | 10..1 |
Type | date, Period |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
184. ExplanationOfBenefit.item.quantity | |
Definition | The number of repetitions of a service or product. |
Short | Count of products or services |
Comments | 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. (42) |
Control | 0..1 |
Type | Quantity(SimpleQuantity) |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required when the product or service code does not convey the quantity provided. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
186. ExplanationOfBenefit.item.noteNumber | |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Short | Applicable note numbers |
Comments | References number of the associated processNote entered |
Control | 0..* |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
188. ExplanationOfBenefit.item.adjudication | |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Adjudication details |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
190. ExplanationOfBenefit.item.adjudication.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
192. ExplanationOfBenefit.item.adjudication.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB Adjudication Category Discriminator Value Sethttp://hl7.org/fhir/ValueSet/adjudication (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
194. ExplanationOfBenefit.item.adjudication:adjustmentreason | |
Slice Name | adjustmentreason |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Reason codes used to interpret the Non-Covered Amount (92)Adjudication details |
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
196. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
198. ExplanationOfBenefit.item.adjudication:adjustmentreason.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
200. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Sethttp://hl7.org/fhir/ValueSet/adjudication-reason (required to http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
202. ExplanationOfBenefit.item.adjudication:allowedunits | |
Slice Name | allowedunits |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | 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)Adjudication details |
Comments | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
204. ExplanationOfBenefit.item.adjudication:allowedunits.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
206. ExplanationOfBenefit.item.adjudication:allowedunits.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
208. ExplanationOfBenefit.item.adjudication:allowedunits.value | |
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. |
Short | Non-monitary value |
Comments | For example: eligible percentage or co-payment percentage. |
Control | 10..1 |
Type | decimal |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | Some adjudication categories convey a percentage or a fixed value. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
210. ExplanationOfBenefit.item.adjudication:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Line level adjudication type and amountAdjudication details |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
212. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
214. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Adjudication Value Sethttp://hl7.org/fhir/ValueSet/adjudication (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
216. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount | |
Definition | Monetary amount associated with the category. |
Short | Monetary amount |
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. |
Control | 10..1 |
Type | Money |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Most adjuciation categories convey a monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
218. ExplanationOfBenefit.adjudication | |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Header-level adjudication |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
220. ExplanationOfBenefit.adjudication.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
222. ExplanationOfBenefit.adjudication.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB Adjudication Category Discriminator Value Sethttp://hl7.org/fhir/ValueSet/adjudication (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
224. ExplanationOfBenefit.adjudication:billingnetworkstatus | |
Slice Name | billingnetworkstatus |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Billing provider networking statusHeader-level adjudication |
Comments | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101) |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
226. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
228. ExplanationOfBenefit.adjudication:billingnetworkstatus.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
230. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Payer Provider Network Status Value Sethttp://hl7.org/fhir/ValueSet/adjudication-reason (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
232. ExplanationOfBenefit.adjudication:benefitpaymentstatus | |
Slice Name | benefitpaymentstatus |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Indicates the in network or out of network payment status of the claim. (142)Header-level adjudication |
Comments | Indicates the in network or out of network payment status of the claim. (142) |
Control | 10..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
234. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
236. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
238. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Payer Benefit Payment Status Value Sethttp://hl7.org/fhir/ValueSet/adjudication-reason (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
240. ExplanationOfBenefit.adjudication:adjustmentreason | |
Slice Name | adjustmentreason |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Reason codes used to interpret the Non-Covered Amount (92)Header-level adjudication |
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
242. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
244. ExplanationOfBenefit.adjudication:adjustmentreason.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
246. ExplanationOfBenefit.adjudication:adjustmentreason.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 10..1 |
Binding | The codes SHALL be taken from For example codes, see X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Sethttp://hl7.org/fhir/ValueSet/adjudication-reason (required to http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
248. ExplanationOfBenefit.adjudication:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Claim level adjudication type and amountHeader-level adjudication |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
250. ExplanationOfBenefit.adjudication:adjudicationamounttype.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
252. ExplanationOfBenefit.adjudication:adjudicationamounttype.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Adjudication Value Sethttp://hl7.org/fhir/ValueSet/adjudication (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
254. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount | |
Definition | Monetary amount associated with the category. |
Short | Monetary amount |
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. |
Control | 10..1 |
Type | Money |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Most adjuciation categories convey a monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
256. ExplanationOfBenefit.total | |
Definition | Categorized monetary totals for the adjudication. |
Short | Adjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.total . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
258. ExplanationOfBenefit.total.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
260. ExplanationOfBenefit.total.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see C4BB Total Category Discriminator Value Sethttp://hl7.org/fhir/ValueSet/adjudication (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
262. ExplanationOfBenefit.total.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Comments | Total amount for each category (i.e., submitted, allowed, etc.) (148) |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
264. ExplanationOfBenefit.total:adjudicationamounttype | |
Slice Name | adjudicationamounttype |
Definition | Categorized monetary totals for the adjudication. |
Short | Total adjudication type and amountAdjudication totals |
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
266. ExplanationOfBenefit.total:adjudicationamounttype.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
268. ExplanationOfBenefit.total:adjudicationamounttype.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Adjudication Value Sethttp://hl7.org/fhir/ValueSet/adjudication (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
270. ExplanationOfBenefit.total:adjudicationamounttype.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
272. ExplanationOfBenefit.payment | |
Definition | Payment details for the adjudication of the claim. |
Short | Payment Details |
Control | 0..1 |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
274. ExplanationOfBenefit.payment.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
276. ExplanationOfBenefit.payment.type | |
Definition | Whether this represents partial or complete payment of the benefits payable. |
Short | Partial or complete payment |
Comments | Indicates whether the claim was paid or denied. (91) |
Control | 0..1 |
Binding | The codes SHALL be taken from For example codes, see C4BB Payer Claim Payment Status Code Value Sethttp://hl7.org/fhir/ValueSet/ex-paymenttype (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To advise the requestor when the insurer believes all payments to have been completed. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
278. ExplanationOfBenefit.payment.date | |
Definition | Estimated date the payment will be issued or the actual issue date of payment. |
Short | Expected date of payment |
Comments | The date the claim was paid. (107) |
Control | 0..1 |
Type | date |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | To advise the payee when payment can be expected. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
280. ExplanationOfBenefit.processNote | |
Definition | A note that describes or explains adjudication results in a human readable form. |
Short | Note concerning adjudication |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Provides the insurer specific textual explanations associated with the processing. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
282. ExplanationOfBenefit.processNote.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
284. ExplanationOfBenefit.processNote.text | |
Definition | The explanation or description associated with the processing. |
Short | Note explanatory text |
Comments | Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181) |
Control | 0..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Requirements | Required to provide human readable explanation. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |||||
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided. | ||||
Short | Explanation of Benefit resource | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | EOB | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )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 ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() )dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() )EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. ( (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not() )EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient EOB: meta.profile with canonical and major.minor. version required. ( meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional|2.1')) )EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both ( adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() ) | ||||
2. ExplanationOfBenefit.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. ExplanationOfBenefit.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 1..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. ExplanationOfBenefit.meta.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
8. ExplanationOfBenefit.meta.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.meta.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
10. ExplanationOfBenefit.meta.versionId | |||||
Definition | The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. | ||||
Short | Version specific identifier | ||||
Comments | The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. ExplanationOfBenefit.meta.lastUpdated | |||||
Definition | When the resource last changed - e.g. when the version changed. | ||||
Short | When the resource version last changed | ||||
Comments | Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last | ||||
Control | 1..1 | ||||
Type | instant | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
14. ExplanationOfBenefit.meta.source | |||||
Definition | A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. | ||||
Short | Identifies where the resource comes from | ||||
Comments | In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
16. ExplanationOfBenefit.meta.profile | |||||
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. | ||||
Short | Profiles this resource claims to conform to | ||||
Comments | 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. CPCDS data element (190) | ||||
Control | 1..* | ||||
Type | canonical(StructureDefinition) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
18. ExplanationOfBenefit.meta.security | |||||
Definition | Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. | ||||
Short | Security Labels applied to this resource | ||||
Comments | The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. | ||||
Control | 0..* | ||||
Binding | Unless not suitable, these codes SHALL be taken from All Security Labels (extensible to http://hl7.org/fhir/ValueSet/security-labels )Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
20. ExplanationOfBenefit.meta.tag | |||||
Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. | ||||
Short | Tags applied to this resource | ||||
Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. | ||||
Control | 0..* | ||||
Binding | For example codes, see CommonTags (example to http://hl7.org/fhir/ValueSet/common-tags )Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. ExplanationOfBenefit.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. ExplanationOfBenefit.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. ExplanationOfBenefit.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. ExplanationOfBenefit.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
30. ExplanationOfBenefit.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
32. ExplanationOfBenefit.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
34. ExplanationOfBenefit.identifier | |||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short | Business Identifier for the resource | ||||
Comments | Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35) | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 1..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
36. ExplanationOfBenefit.identifier:uniqueclaimid | |||||
Slice Name | uniqueclaimid | ||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short | Unique Claim Identifier | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 1..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. ExplanationOfBenefit.identifier:uniqueclaimid.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
40. ExplanationOfBenefit.identifier:uniqueclaimid.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
42. ExplanationOfBenefit.identifier:uniqueclaimid.use | |||||
Definition | The purpose of this identifier. | ||||
Short | usual | official | temp | secondary | old (If known) | ||||
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from IdentifierUse (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 )Identifies the purpose for this identifier, if known . | ||||
Type | code | ||||
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. ExplanationOfBenefit.identifier:uniqueclaimid.type | |||||
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||||
Short | Description of identifier | ||||
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to http://hl7.org/fhir/ValueSet/identifier-type )A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. ExplanationOfBenefit.identifier:uniqueclaimid.system | |||||
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||||
Short | The namespace for the identifier value | ||||
Comments | Identifier.system is always case sensitive. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||||
Example | <br/><b>General</b>:http://www.acme.com/identifiers/patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. ExplanationOfBenefit.identifier:uniqueclaimid.value | |||||
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||||
Short | Unique Claim Identifier | ||||
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. | ||||
Control | 1..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Example | <br/><b>General</b>:123456 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. ExplanationOfBenefit.identifier:uniqueclaimid.period | |||||
Definition | Time period during which identifier is/was valid for use. | ||||
Short | Time period when id is/was valid for use | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. ExplanationOfBenefit.identifier:uniqueclaimid.assigner | |||||
Definition | Organization that issued/manages the identifier. | ||||
Short | Organization that issued id (may be just text) | ||||
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. | ||||
Control | 0..1 | ||||
Type | Reference(Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. ExplanationOfBenefit.status | |||||
Definition | The status of the resource instance. | ||||
Short | active | cancelled | draft | entered-in-error | ||||
Comments | Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from ExplanationOfBenefitStatus (required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 )A code specifying the state of the resource instance. | ||||
Type | code | ||||
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. ExplanationOfBenefit.type | |||||
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | ||||
Short | Category or discipline | ||||
Comments | Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from ClaimTypeCodes (required to http://hl7.org/fhir/ValueSet/claim-type ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. ExplanationOfBenefit.subType | |||||
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | ||||
Short | More granular claim type | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Institutional Claim SubType Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. ExplanationOfBenefit.use | |||||
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. | ||||
Short | claim | preauthorization | predetermination | ||||
Comments | Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from Use (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 )Complete, proposed, exploratory, other. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | This element is required to understand the nature of the request for adjudication. | ||||
Pattern Value | claim | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. ExplanationOfBenefit.patient | |||||
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. | ||||
Short | The recipient of the products and services | ||||
Comments | Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier | ||||
Control | 1..1 | ||||
Type | Reference(C4BB Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. ExplanationOfBenefit.billablePeriod | |||||
Definition | The period for which charges are being submitted. | ||||
Short | Relevant time frame for the claim | ||||
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. | ||||
Control | 1..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. ExplanationOfBenefit.billablePeriod.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
68. ExplanationOfBenefit.billablePeriod.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.billablePeriod.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
70. ExplanationOfBenefit.billablePeriod.start | |||||
Definition | The start of the period. The boundary is inclusive. | ||||
Short | Starting time with inclusive boundary | ||||
Comments | The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177) | ||||
Control | 1..1 This element is affected by the following invariants: per-1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
72. ExplanationOfBenefit.billablePeriod.end | |||||
Definition | The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time. | ||||
Short | End time with inclusive boundary, if not ongoing | ||||
Comments | The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178) | ||||
Control | 0..1 This element is affected by the following invariants: per-1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Meaning if Missing | If the end of the period is missing, it means that the period is ongoing | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. ExplanationOfBenefit.created | |||||
Definition | The date this resource was created. | ||||
Short | Response creation date | ||||
Comments | Date the claim was adjudicated (179) | ||||
Control | 1..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Need to record a timestamp for use by both the recipient and the issuer. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. ExplanationOfBenefit.enterer | |||||
Definition | Individual who created the claim, predetermination or preauthorization. | ||||
Short | Author of the claim | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some jurisdictions require the contact information for personnel completing claims. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. ExplanationOfBenefit.insurer | |||||
Definition | The party responsible for authorization, adjudication and reimbursement. | ||||
Short | Party responsible for reimbursement | ||||
Comments | Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider | ||||
Control | 1..1 | ||||
Type | Reference(C4BB Organization) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. ExplanationOfBenefit.provider | |||||
Definition | The provider which is responsible for the claim, predetermination or preauthorization. | ||||
Short | Party responsible for the claim | ||||
Comments | The identifier assigned to the Billing Provider. (94) | ||||
Control | 1..1 | ||||
Type | Reference(C4BB Organization) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. ExplanationOfBenefit.priority | |||||
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | ||||
Short | Desired processing urgency | ||||
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to http://hl7.org/fhir/ValueSet/process-priority ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. ExplanationOfBenefit.fundsReserveRequested | |||||
Definition | A code to indicate whether and for whom funds are to be reserved for future claims. | ||||
Short | For whom to reserve funds | ||||
Comments | This field is only used for preauthorizations. | ||||
Control | 0..1 | ||||
Binding | For example codes, see Funds Reservation Codes (example to http://hl7.org/fhir/ValueSet/fundsreserve )For whom funds are to be reserved: (Patient, Provider, None). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested. | ||||
Alternate Names | Fund pre-allocation | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. ExplanationOfBenefit.fundsReserve | |||||
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | ||||
Short | Funds reserved status | ||||
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. | ||||
Control | 0..1 | ||||
Binding | For example codes, see Funds Reservation Codes (example to http://hl7.org/fhir/ValueSet/fundsreserve )For whom funds are to be reserved: (Patient, Provider, None). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. ExplanationOfBenefit.related | |||||
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | ||||
Short | Prior or corollary claims | ||||
Comments | If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112) | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. ExplanationOfBenefit.related.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
92. ExplanationOfBenefit.related.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
94. ExplanationOfBenefit.related.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
96. ExplanationOfBenefit.related.claim | |||||
Definition | Reference to a related claim. | ||||
Short | Reference to the related claim | ||||
Control | 0..1 | ||||
Type | Reference(Claim) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. ExplanationOfBenefit.related.relationship | |||||
Definition | A code to convey how the claims are related. | ||||
Short | How the reference claim is related | ||||
Comments | For example, prior claim or umbrella. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Related Claim Relationship Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers need a declaration of the type of relationship. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. ExplanationOfBenefit.related.reference | |||||
Definition | An alternate organizational reference to the case or file to which this particular claim pertains. | ||||
Short | File or case reference | ||||
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number. | ||||
Control | 1..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
102. ExplanationOfBenefit.prescription | |||||
Definition | Prescription to support the dispensing of pharmacy, device or vision products. | ||||
Short | Prescription authorizing services or products | ||||
Control | 0..1 | ||||
Type | Reference(MedicationRequest, VisionPrescription) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to authorize the dispensing of controlled substances and devices. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
104. ExplanationOfBenefit.originalPrescription | |||||
Definition | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | ||||
Short | Original prescription if superceded by fulfiller | ||||
Comments | For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'. | ||||
Control | 0..1 | ||||
Type | Reference(MedicationRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
106. ExplanationOfBenefit.payee | |||||
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy. | ||||
Short | Recipient of benefits payable | ||||
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead. | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required ( type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists() ) | ||||
108. ExplanationOfBenefit.payee.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
110. ExplanationOfBenefit.payee.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
112. ExplanationOfBenefit.payee.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
114. ExplanationOfBenefit.payee.type | |||||
Definition | Type of Party to be reimbursed: Subscriber, provider, other. | ||||
Short | Category of recipient | ||||
Comments | Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120) | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Payee Type Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
116. ExplanationOfBenefit.payee.party | |||||
Definition | Reference to the individual or organization to whom any payment will be made. | ||||
Short | Recipient reference | ||||
Comments | Recipient reference (121) | ||||
Control | 0..1 | ||||
Type | Reference(C4BB Organization, C4BB Patient, C4BB Practitioner, C4BB RelatedPerson) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | false | ||||
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
118. ExplanationOfBenefit.referral | |||||
Definition | A reference to a referral resource. | ||||
Short | Treatment Referral | ||||
Comments | The referral resource which lists the date, practitioner, reason and other supporting information. | ||||
Control | 0..1 | ||||
Type | Reference(ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
120. ExplanationOfBenefit.facility | |||||
Definition | Facility where the services were provided. | ||||
Short | Servicing Facility | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Insurance adjudication can be dependant on where services were delivered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
122. ExplanationOfBenefit.claim | |||||
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | ||||
Short | Claim reference | ||||
Control | 0..1 | ||||
Type | Reference(Claim) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To provide a link to the original adjudication request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
124. ExplanationOfBenefit.claimResponse | |||||
Definition | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response. | ||||
Short | Claim response reference | ||||
Control | 0..1 | ||||
Type | Reference(ClaimResponse) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To provide a link to the original adjudication response. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
126. ExplanationOfBenefit.outcome | |||||
Definition | The outcome of the claim, predetermination, or preauthorization processing. | ||||
Short | queued | complete | error | partial | ||||
Comments | Expected value is complete | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from ClaimProcessingCodes (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 )The result of the claim processing. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | To advise the requestor of an overall processing outcome. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
128. ExplanationOfBenefit.disposition | |||||
Definition | A human readable description of the status of the adjudication. | ||||
Short | Disposition Message | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provided for user display. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
130. ExplanationOfBenefit.preAuthRef | |||||
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication. | ||||
Short | Preauthorization reference | ||||
Comments | This value is only present on preauthorization adjudications. | ||||
Control | 0..* | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | On subsequent claims, the insurer may require the provider to quote this value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
132. ExplanationOfBenefit.preAuthRefPeriod | |||||
Definition | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided. | ||||
Short | Preauthorization in-effect period | ||||
Comments | This value is only present on preauthorization adjudications. | ||||
Control | 0..* | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | On subsequent claims, the insurer may require the provider to quote this value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
134. ExplanationOfBenefit.careTeam | |||||
Definition | The members of the team who provided the products and services. | ||||
Short | Care Team members | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Common to identify the responsible and supporting practitioners. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner ( (
role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies
provider.all(resolve() is Practitioner)
) )EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization ( (
role.where(coding.where(code in ('rendering' )).exists()).exists() implies
provider.all(resolve() is Organization)
) )EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set ( where(role.where(coding.code in ('rendering')).exists().not() or qualification.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066')).exists() ) | ||||
136. ExplanationOfBenefit.careTeam.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
138. ExplanationOfBenefit.careTeam.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
140. ExplanationOfBenefit.careTeam.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
142. ExplanationOfBenefit.careTeam.sequence | |||||
Definition | A number to uniquely identify care team entries. | ||||
Short | Order of care team | ||||
Comments | careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
144. ExplanationOfBenefit.careTeam.provider | |||||
Definition | Member of the team who provided the product or service. | ||||
Short | Practitioner or organization | ||||
Comments | The identifier assigned to the care team. (varies depending on the profile) | ||||
Control | 1..1 | ||||
Type | Reference(C4BB Organization, C4BB Practitioner) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | false | ||||
Requirements | Often a regulatory requirement to specify the responsible provider. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
146. ExplanationOfBenefit.careTeam.responsible | |||||
Definition | The party who is billing and/or responsible for the claimed products or services. | ||||
Short | Indicator of the lead practitioner | ||||
Comments | Responsible might not be required when there is only a single provider listed. | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
148. ExplanationOfBenefit.careTeam.role | |||||
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. | ||||
Short | Function within the team | ||||
Comments | The functional role of a provider on a claim. (165) | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Claim Institutional Care Team Role Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
150. ExplanationOfBenefit.careTeam.qualification | |||||
Definition | The qualification of the practitioner which is applicable for this service. | ||||
Short | Practitioner credential or specialization | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from Healthcare Provider Taxonomy (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Need to specify which qualification a provider is delivering the product or service under. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
152. ExplanationOfBenefit.supportingInfo | |||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Supporting information | ||||
Comments | Defines data elements not available in the base EOB resource | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
154. ExplanationOfBenefit.supportingInfo.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
156. ExplanationOfBenefit.supportingInfo.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
158. ExplanationOfBenefit.supportingInfo.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
160. ExplanationOfBenefit.supportingInfo.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
162. ExplanationOfBenefit.supportingInfo.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
164. ExplanationOfBenefit.supportingInfo.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExceptionCodes (example to http://hl7.org/fhir/ValueSet/claim-exception )The valuset used for additional information codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
166. ExplanationOfBenefit.supportingInfo.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
168. ExplanationOfBenefit.supportingInfo.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
170. ExplanationOfBenefit.supportingInfo.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
172. ExplanationOfBenefit.supportingInfo:clmrecvddate | |||||
Slice Name | clmrecvddate | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Claim received date | ||||
Comments | The date the claim was received by the payer (88) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
174. ExplanationOfBenefit.supportingInfo:clmrecvddate.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
176. ExplanationOfBenefit.supportingInfo:clmrecvddate.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
178. ExplanationOfBenefit.supportingInfo:clmrecvddate.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
180. ExplanationOfBenefit.supportingInfo:clmrecvddate.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
182. ExplanationOfBenefit.supportingInfo:clmrecvddate.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
184. ExplanationOfBenefit.supportingInfo:clmrecvddate.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExceptionCodes (example to http://hl7.org/fhir/ValueSet/claim-exception )The valuset used for additional information codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
186. ExplanationOfBenefit.supportingInfo:clmrecvddate.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 1..1 | ||||
Type | date | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
188. ExplanationOfBenefit.supportingInfo:clmrecvddate.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
190. ExplanationOfBenefit.supportingInfo:clmrecvddate.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
192. ExplanationOfBenefit.supportingInfo:typeofbill | |||||
Slice Name | typeofbill | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Type of bill | ||||
Comments | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
194. ExplanationOfBenefit.supportingInfo:typeofbill.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
196. ExplanationOfBenefit.supportingInfo:typeofbill.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
198. ExplanationOfBenefit.supportingInfo:typeofbill.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
200. ExplanationOfBenefit.supportingInfo:typeofbill.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
202. ExplanationOfBenefit.supportingInfo:typeofbill.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
204. ExplanationOfBenefit.supportingInfo:typeofbill.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from NUBC Type of Bill Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
206. ExplanationOfBenefit.supportingInfo:typeofbill.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
208. ExplanationOfBenefit.supportingInfo:typeofbill.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
210. ExplanationOfBenefit.supportingInfo:typeofbill.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
212. ExplanationOfBenefit.supportingInfo:pointoforigin | |||||
Slice Name | pointoforigin | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Point of origin for admission or visit | ||||
Comments | Identifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
214. ExplanationOfBenefit.supportingInfo:pointoforigin.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
216. ExplanationOfBenefit.supportingInfo:pointoforigin.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
218. ExplanationOfBenefit.supportingInfo:pointoforigin.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
220. ExplanationOfBenefit.supportingInfo:pointoforigin.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
222. ExplanationOfBenefit.supportingInfo:pointoforigin.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
224. ExplanationOfBenefit.supportingInfo:pointoforigin.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from NUBC Point Of Origin Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
226. ExplanationOfBenefit.supportingInfo:pointoforigin.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
228. ExplanationOfBenefit.supportingInfo:pointoforigin.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
230. ExplanationOfBenefit.supportingInfo:pointoforigin.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
232. ExplanationOfBenefit.supportingInfo:admtype | |||||
Slice Name | admtype | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Admission type | ||||
Comments | Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. (14) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
234. ExplanationOfBenefit.supportingInfo:admtype.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
236. ExplanationOfBenefit.supportingInfo:admtype.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
238. ExplanationOfBenefit.supportingInfo:admtype.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
240. ExplanationOfBenefit.supportingInfo:admtype.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
242. ExplanationOfBenefit.supportingInfo:admtype.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
244. ExplanationOfBenefit.supportingInfo:admtype.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from NUBC Priority (Type) of Admission or Visit Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
246. ExplanationOfBenefit.supportingInfo:admtype.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
248. ExplanationOfBenefit.supportingInfo:admtype.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
250. ExplanationOfBenefit.supportingInfo:admtype.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
252. ExplanationOfBenefit.supportingInfo:discharge-status | |||||
Slice Name | discharge-status | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Discharge status | ||||
Comments | Patient’s status as of the discharge date for a facility stay. Information located on UB04. (Form Locator 17). (117) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
254. ExplanationOfBenefit.supportingInfo:discharge-status.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
256. ExplanationOfBenefit.supportingInfo:discharge-status.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
258. ExplanationOfBenefit.supportingInfo:discharge-status.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
260. ExplanationOfBenefit.supportingInfo:discharge-status.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
262. ExplanationOfBenefit.supportingInfo:discharge-status.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
264. ExplanationOfBenefit.supportingInfo:discharge-status.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from NUBC Patient Discharge Status Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
266. ExplanationOfBenefit.supportingInfo:discharge-status.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
268. ExplanationOfBenefit.supportingInfo:discharge-status.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 0..1 | ||||
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
270. ExplanationOfBenefit.supportingInfo:discharge-status.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
272. ExplanationOfBenefit.supportingInfo:medicalrecordnumber | |||||
Slice Name | medicalrecordnumber | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Medical record number | ||||
Comments | Provider submitted medical record number that can be included on the claim. (109) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
274. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
276. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
278. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
280. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
282. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
284. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExceptionCodes (example to http://hl7.org/fhir/ValueSet/claim-exception )The valuset used for additional information codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
286. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
288. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x] . The slices areUnordered and Closed, and can be differentiated using the following discriminators: | ||||
290. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]:valueString | |||||
Slice Name | valueString | ||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
292. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
294. ExplanationOfBenefit.supportingInfo:patientaccountnumber | |||||
Slice Name | patientaccountnumber | ||||
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | ||||
Short | Patient account number | ||||
Comments | Provider assigned patient account number that can be included on the claim. (109) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
296. ExplanationOfBenefit.supportingInfo:patientaccountnumber.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
298. ExplanationOfBenefit.supportingInfo:patientaccountnumber.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
300. ExplanationOfBenefit.supportingInfo:patientaccountnumber.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
302. ExplanationOfBenefit.supportingInfo:patientaccountnumber.sequence | |||||
Definition | A number to uniquely identify supporting information entries. | ||||
Short | Information instance identifier | ||||
Comments | Client app implementations should look-up supportingInfo elements based on category values instead of sequence values | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
304. ExplanationOfBenefit.supportingInfo:patientaccountnumber.category | |||||
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc. | ||||
Short | Classification of the supplied information | ||||
Comments | This may contain a category for the local bill type codes. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB SupportingInfo Type Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
306. ExplanationOfBenefit.supportingInfo:patientaccountnumber.code | |||||
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | ||||
Short | Type of information | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExceptionCodes (example to http://hl7.org/fhir/ValueSet/claim-exception )The valuset used for additional information codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to identify the kind of additional information. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
308. ExplanationOfBenefit.supportingInfo:patientaccountnumber.timing[x] | |||||
Definition | The date when or period to which this information refers. | ||||
Short | When it occurred | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
310. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x] | |||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x] . The slices areUnordered and Closed, and can be differentiated using the following discriminators: | ||||
312. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]:valueString | |||||
Slice Name | valueString | ||||
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | ||||
Short | Data to be provided | ||||
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident. | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To convey the data content to be provided when the information is more than a simple code or period. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
314. ExplanationOfBenefit.supportingInfo:patientaccountnumber.reason | |||||
Definition | Provides the reason in the situation where a reason code is required in addition to the content. | ||||
Short | Explanation for the information | ||||
Comments | For example: the reason for the additional stay, or why a tooth is missing. | ||||
Control | 0..1 | ||||
Binding | For example codes, see MissingToothReasonCodes (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason )Reason codes for the missing teeth. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
316. ExplanationOfBenefit.diagnosis | |||||
Definition | Information about diagnoses relevant to the claim items. | ||||
Short | Pertinent diagnosis information | ||||
Comments | Diagnosis codes describe an individual's disease or medical condition. (6, 7, 8, 21, 22, 23, 30) | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required for the adjudication by provided context for the services and product listed. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
318. ExplanationOfBenefit.diagnosis.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
320. ExplanationOfBenefit.diagnosis.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
322. ExplanationOfBenefit.diagnosis.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
324. ExplanationOfBenefit.diagnosis.sequence | |||||
Definition | A number to uniquely identify diagnosis entries. | ||||
Short | Diagnosis instance identifier | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
326. ExplanationOfBenefit.diagnosis.diagnosis[x] | |||||
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition. | ||||
Short | Nature of illness or problem | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes ) | ||||
Type | CodeableConcept | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Provides health context for the evaluation of the products and/or services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
328. ExplanationOfBenefit.diagnosis.type | |||||
Definition | When the condition was observed or the relative ranking. | ||||
Short | Timing or nature of the diagnosis | ||||
Comments | Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit. (21, 22, 23) | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Claim Outpatient Institutional Diagnosis Type Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimOutpatientInstitutionalDiagnosisType ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
330. ExplanationOfBenefit.diagnosis.onAdmission | |||||
Definition | Indication of whether the diagnosis was present on admission to a facility. | ||||
Short | Present on admission | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission )Present on admission. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
332. ExplanationOfBenefit.diagnosis.packageCode | |||||
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system. | ||||
Short | Package billing code | ||||
Comments | For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup )The DRG codes associated with the diagnosis. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
334. ExplanationOfBenefit.procedure | |||||
Definition | Procedures performed on the patient relevant to the billing items with the claim. | ||||
Short | Clinical procedures performed | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
336. ExplanationOfBenefit.procedure.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
338. ExplanationOfBenefit.procedure.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
340. ExplanationOfBenefit.procedure.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
342. ExplanationOfBenefit.procedure.sequence | |||||
Definition | A number to uniquely identify procedure entries. | ||||
Short | Procedure instance identifier | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to provide a mechanism to link to claim details. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
344. ExplanationOfBenefit.procedure.type | |||||
Definition | When the condition was observed or the relative ranking. | ||||
Short | Category of Procedure | ||||
Control | 0..* | ||||
Binding | For example codes, see ExampleProcedureTypeCodes (example to http://hl7.org/fhir/ValueSet/ex-procedure-type )Example procedure type codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
346. ExplanationOfBenefit.procedure.date | |||||
Definition | Date and optionally time the procedure was performed. | ||||
Short | When the procedure was performed | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Required for auditing purposes. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
348. ExplanationOfBenefit.procedure.procedure[x] | |||||
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed. | ||||
Short | Specific clinical procedure | ||||
Control | 1..1 | ||||
Binding | For example codes, see ICD-10ProcedureCodes (example to http://hl7.org/fhir/ValueSet/icd-10-procedures )ICD10 Procedure codes. | ||||
Type | Choice of: CodeableConcept, Reference(Procedure) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | This identifies the actual clinical procedure. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
350. ExplanationOfBenefit.procedure.udi | |||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short | Unique device identifier | ||||
Control | 0..* | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
352. ExplanationOfBenefit.precedence | |||||
Definition | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services. | ||||
Short | Precedence (primary, secondary, etc.) | ||||
Control | 0..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to coordinate between multiple EOBs for the same suite of services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
354. ExplanationOfBenefit.insurance | |||||
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim. | ||||
Short | Patient insurance information | ||||
Comments | Identity of the payers responsible for the claim. (2, 141). All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True' | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | At least one insurer is required for a claim to be a claim. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )EOB-insurance-focal: EOB.insurance: at most one with focal = true ( select (focal = true).count() < 2 ) | ||||
356. ExplanationOfBenefit.insurance.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
358. ExplanationOfBenefit.insurance.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
360. ExplanationOfBenefit.insurance.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
362. ExplanationOfBenefit.insurance.focal | |||||
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. | ||||
Short | Coverage to be used for adjudication | ||||
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True' | ||||
Control | 1..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | To identify which coverage in the list is being used to adjudicate this claim. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
364. ExplanationOfBenefit.insurance.coverage | |||||
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. | ||||
Short | Insurance information | ||||
Comments | Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier] | ||||
Control | 1..1 | ||||
Type | Reference(C4BB Coverage) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
366. ExplanationOfBenefit.insurance.preAuthRef | |||||
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization. | ||||
Short | Prior authorization reference number | ||||
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier. | ||||
Control | 0..* | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
368. ExplanationOfBenefit.accident | |||||
Definition | Details of a accident which resulted in injuries which required the products and services listed in the claim. | ||||
Short | Details of the event | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
370. ExplanationOfBenefit.accident.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
372. ExplanationOfBenefit.accident.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
374. ExplanationOfBenefit.accident.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
376. ExplanationOfBenefit.accident.date | |||||
Definition | Date of an accident event related to the products and services contained in the claim. | ||||
Short | When the incident occurred | ||||
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe. | ||||
Control | 0..1 | ||||
Type | date | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Required for audit purposes and adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
378. ExplanationOfBenefit.accident.type | |||||
Definition | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. | ||||
Short | The nature of the accident | ||||
Control | 0..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ActIncidentCode (extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode )Type of accident: work place, auto, etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Coverage may be dependant on the type of accident. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
380. ExplanationOfBenefit.accident.location[x] | |||||
Definition | The physical location of the accident event. | ||||
Short | Where the event occurred | ||||
Control | 0..1 | ||||
Type | Choice of: Address, Reference(Location) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required for audit purposes and determination of applicable insurance liability. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
382. ExplanationOfBenefit.item | |||||
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. | ||||
Short | Product or service provided | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The items to be processed for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ( (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()) ) | ||||
384. ExplanationOfBenefit.item.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
386. ExplanationOfBenefit.item.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
388. ExplanationOfBenefit.item.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
390. ExplanationOfBenefit.item.sequence | |||||
Definition | A number to uniquely identify item entries. | ||||
Short | Item instance identifier | ||||
Comments | Line identification number that represents the number assigned in a source system for identification and processing. (36) | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
392. ExplanationOfBenefit.item.careTeamSequence | |||||
Definition | Care team members related to this service or product. | ||||
Short | Applicable care team members | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Need to identify the individuals and their roles in the provision of the product or service. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
394. ExplanationOfBenefit.item.diagnosisSequence | |||||
Definition | Diagnoses applicable for this service or product. | ||||
Short | Applicable diagnoses | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Need to related the product or service to the associated diagnoses. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
396. ExplanationOfBenefit.item.procedureSequence | |||||
Definition | Procedures applicable for this service or product. | ||||
Short | Applicable procedures | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Need to provide any listed specific procedures to support the product or service being claimed. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
398. ExplanationOfBenefit.item.informationSequence | |||||
Definition | Exceptions, special conditions and supporting information applicable for this service or product. | ||||
Short | Applicable exception and supporting information | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Need to reference the supporting information items that relate directly to this product or service. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
400. ExplanationOfBenefit.item.revenue | |||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short | Revenue or cost center code | ||||
Comments | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86) | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from NUBC Revenue Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
402. ExplanationOfBenefit.item.category | |||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short | Benefit classification | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
Control | 0..1 | ||||
Binding | For example codes, see BenefitCategoryCodes (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory )Benefit categories such as: oral, medical, vision, oral-basic etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
404. ExplanationOfBenefit.item.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40) | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
406. ExplanationOfBenefit.item.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Product or service billing modifiers | ||||
Comments | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41) | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
408. ExplanationOfBenefit.item.programCode | |||||
Definition | Identifies the program under which this may be recovered. | ||||
Short | Program the product or service is provided under | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
Control | 0..* | ||||
Binding | For example codes, see ExampleProgramReasonCodes (example to http://hl7.org/fhir/ValueSet/ex-program-code )Program specific reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
410. ExplanationOfBenefit.item.serviced[x] | |||||
Definition | The date or dates when the service or product was supplied, performed or completed. | ||||
Short | Date or dates of service or product delivery | ||||
Control | 1..1 | ||||
Type | date | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
412. ExplanationOfBenefit.item.location[x] | |||||
Definition | Where the product or service was provided. | ||||
Short | Place of service or where product was supplied | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleServicePlaceCodes (example to http://hl7.org/fhir/ValueSet/service-place )Place where the service is rendered. | ||||
Type | Choice of: CodeableConcept, Address, Reference(Location) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
414. ExplanationOfBenefit.item.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Comments | 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. (42) | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
416. ExplanationOfBenefit.item.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
418. ExplanationOfBenefit.item.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
420. ExplanationOfBenefit.item.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
422. ExplanationOfBenefit.item.udi | |||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short | Unique device identifier | ||||
Control | 0..* | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
424. ExplanationOfBenefit.item.bodySite | |||||
Definition | Physical service site on the patient (limb, tooth, etc.). | ||||
Short | Anatomical location | ||||
Comments | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. | ||||
Control | 0..1 | ||||
Binding | For example codes, see OralSiteCodes (example to http://hl7.org/fhir/ValueSet/tooth )The code for the teeth, quadrant, sextant and arch. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
426. ExplanationOfBenefit.item.subSite | |||||
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s). | ||||
Short | Anatomical sub-location | ||||
Control | 0..* | ||||
Binding | For example codes, see SurfaceCodes (example to http://hl7.org/fhir/ValueSet/surface )The code for the tooth surface and surface combinations. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
428. ExplanationOfBenefit.item.encounter | |||||
Definition | A billed item may include goods or services provided in multiple encounters. | ||||
Short | Encounters related to this billed item | ||||
Control | 0..* | ||||
Type | Reference(Encounter) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Used in some jurisdictions to link clinical events to claim items. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
430. ExplanationOfBenefit.item.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Comments | References number of the associated processNote entered | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
432. ExplanationOfBenefit.item.adjudication | |||||
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. | ||||
Short | Adjudication details | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
434. ExplanationOfBenefit.item.adjudication.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
436. ExplanationOfBenefit.item.adjudication.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
438. ExplanationOfBenefit.item.adjudication.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
440. ExplanationOfBenefit.item.adjudication.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
442. ExplanationOfBenefit.item.adjudication.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 0..1 | ||||
Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason )Adjudication reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
444. ExplanationOfBenefit.item.adjudication.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
446. ExplanationOfBenefit.item.adjudication.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
448. ExplanationOfBenefit.item.adjudication:adjustmentreason | |||||
Slice Name | adjustmentreason | ||||
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. | ||||
Short | Reason codes used to interpret the Non-Covered Amount (92) | ||||
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
450. ExplanationOfBenefit.item.adjudication:adjustmentreason.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
452. ExplanationOfBenefit.item.adjudication:adjustmentreason.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
454. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
456. ExplanationOfBenefit.item.adjudication:adjustmentreason.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
458. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
460. ExplanationOfBenefit.item.adjudication:adjustmentreason.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
462. ExplanationOfBenefit.item.adjudication:adjustmentreason.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
464. ExplanationOfBenefit.item.adjudication:allowedunits | |||||
Slice Name | allowedunits | ||||
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. | ||||
Short | 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) | ||||
Comments | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
466. ExplanationOfBenefit.item.adjudication:allowedunits.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
468. ExplanationOfBenefit.item.adjudication:allowedunits.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
470. ExplanationOfBenefit.item.adjudication:allowedunits.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
472. ExplanationOfBenefit.item.adjudication:allowedunits.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
474. ExplanationOfBenefit.item.adjudication:allowedunits.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 0..1 | ||||
Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason )Adjudication reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
476. ExplanationOfBenefit.item.adjudication:allowedunits.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
478. ExplanationOfBenefit.item.adjudication:allowedunits.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 1..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
480. ExplanationOfBenefit.item.adjudication:adjudicationamounttype | |||||
Slice Name | adjudicationamounttype | ||||
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. | ||||
Short | Line level adjudication type and amount | ||||
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
482. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
484. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
486. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
488. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
490. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 0..1 | ||||
Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason )Adjudication reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
492. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 1..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
494. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
496. ExplanationOfBenefit.item.detail | |||||
Definition | Second-tier of goods and services. | ||||
Short | Additional items | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
498. ExplanationOfBenefit.item.detail.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
500. ExplanationOfBenefit.item.detail.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
502. ExplanationOfBenefit.item.detail.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
504. ExplanationOfBenefit.item.detail.sequence | |||||
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | ||||
Short | Product or service provided | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | The items to be processed for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
506. ExplanationOfBenefit.item.detail.revenue | |||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short | Revenue or cost center code | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleRevenueCenterCodes (example to http://hl7.org/fhir/ValueSet/ex-revenue-center )Codes for the revenue or cost centers supplying the service and/or products. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
508. ExplanationOfBenefit.item.detail.category | |||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short | Benefit classification | ||||
Comments | Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
Control | 0..1 | ||||
Binding | For example codes, see BenefitCategoryCodes (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory )Benefit categories such as: oral, medical, vision, oral-basic etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
510. ExplanationOfBenefit.item.detail.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
Control | 1..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
512. ExplanationOfBenefit.item.detail.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Service/Product billing modifiers | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
514. ExplanationOfBenefit.item.detail.programCode | |||||
Definition | Identifies the program under which this may be recovered. | ||||
Short | Program the product or service is provided under | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
Control | 0..* | ||||
Binding | For example codes, see ExampleProgramReasonCodes (example to http://hl7.org/fhir/ValueSet/ex-program-code )Program specific reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
516. ExplanationOfBenefit.item.detail.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
518. ExplanationOfBenefit.item.detail.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
520. ExplanationOfBenefit.item.detail.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
522. ExplanationOfBenefit.item.detail.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
524. ExplanationOfBenefit.item.detail.udi | |||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short | Unique device identifier | ||||
Control | 0..* | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
526. ExplanationOfBenefit.item.detail.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
528. ExplanationOfBenefit.item.detail.adjudication | |||||
Definition | The adjudication results. | ||||
Short | Detail level adjudication details | ||||
Control | 0..* | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
530. ExplanationOfBenefit.item.detail.subDetail | |||||
Definition | Third-tier of goods and services. | ||||
Short | Additional items | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
532. ExplanationOfBenefit.item.detail.subDetail.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
534. ExplanationOfBenefit.item.detail.subDetail.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
536. ExplanationOfBenefit.item.detail.subDetail.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
538. ExplanationOfBenefit.item.detail.subDetail.sequence | |||||
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | ||||
Short | Product or service provided | ||||
Control | 1..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | The items to be processed for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
540. ExplanationOfBenefit.item.detail.subDetail.revenue | |||||
Definition | The type of revenue or cost center providing the product and/or service. | ||||
Short | Revenue or cost center code | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleRevenueCenterCodes (example to http://hl7.org/fhir/ValueSet/ex-revenue-center )Codes for the revenue or cost centers supplying the service and/or products. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
542. ExplanationOfBenefit.item.detail.subDetail.category | |||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short | Benefit classification | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
Control | 0..1 | ||||
Binding | For example codes, see BenefitCategoryCodes (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory )Benefit categories such as: oral, medical, vision, oral-basic etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
544. ExplanationOfBenefit.item.detail.subDetail.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
Control | 1..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
546. ExplanationOfBenefit.item.detail.subDetail.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Service/Product billing modifiers | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
548. ExplanationOfBenefit.item.detail.subDetail.programCode | |||||
Definition | Identifies the program under which this may be recovered. | ||||
Short | Program the product or service is provided under | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
Control | 0..* | ||||
Binding | For example codes, see ExampleProgramReasonCodes (example to http://hl7.org/fhir/ValueSet/ex-program-code )Program specific reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
550. ExplanationOfBenefit.item.detail.subDetail.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
552. ExplanationOfBenefit.item.detail.subDetail.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
554. ExplanationOfBenefit.item.detail.subDetail.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
556. ExplanationOfBenefit.item.detail.subDetail.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
558. ExplanationOfBenefit.item.detail.subDetail.udi | |||||
Definition | Unique Device Identifiers associated with this line item. | ||||
Short | Unique device identifier | ||||
Control | 0..* | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
560. ExplanationOfBenefit.item.detail.subDetail.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
562. ExplanationOfBenefit.item.detail.subDetail.adjudication | |||||
Definition | The adjudication results. | ||||
Short | Subdetail level adjudication details | ||||
Control | 0..* | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
564. ExplanationOfBenefit.addItem | |||||
Definition | The first-tier service adjudications for payor added product or service lines. | ||||
Short | Insurer added line items | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
566. ExplanationOfBenefit.addItem.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
568. ExplanationOfBenefit.addItem.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
570. ExplanationOfBenefit.addItem.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
572. ExplanationOfBenefit.addItem.itemSequence | |||||
Definition | Claim items which this service line is intended to replace. | ||||
Short | Item sequence number | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides references to the claim items. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
574. ExplanationOfBenefit.addItem.detailSequence | |||||
Definition | The sequence number of the details within the claim item which this line is intended to replace. | ||||
Short | Detail sequence number | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides references to the claim details within the claim item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
576. ExplanationOfBenefit.addItem.subDetailSequence | |||||
Definition | The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace. | ||||
Short | Subdetail sequence number | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides references to the claim sub-details within the claim detail. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
578. ExplanationOfBenefit.addItem.provider | |||||
Definition | The providers who are authorized for the services rendered to the patient. | ||||
Short | Authorized providers | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
580. ExplanationOfBenefit.addItem.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
Control | 1..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
582. ExplanationOfBenefit.addItem.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Service/Product billing modifiers | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
584. ExplanationOfBenefit.addItem.programCode | |||||
Definition | Identifies the program under which this may be recovered. | ||||
Short | Program the product or service is provided under | ||||
Comments | For example: Neonatal program, child dental program or drug users recovery program. | ||||
Control | 0..* | ||||
Binding | For example codes, see ExampleProgramReasonCodes (example to http://hl7.org/fhir/ValueSet/ex-program-code )Program specific reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
586. ExplanationOfBenefit.addItem.serviced[x] | |||||
Definition | The date or dates when the service or product was supplied, performed or completed. | ||||
Short | Date or dates of service or product delivery | ||||
Control | 0..1 | ||||
Type | Choice of: date, Period | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
588. ExplanationOfBenefit.addItem.location[x] | |||||
Definition | Where the product or service was provided. | ||||
Short | Place of service or where product was supplied | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleServicePlaceCodes (example to http://hl7.org/fhir/ValueSet/service-place )Place where the service is rendered. | ||||
Type | Choice of: CodeableConcept, Address, Reference(Location) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
590. ExplanationOfBenefit.addItem.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
592. ExplanationOfBenefit.addItem.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
594. ExplanationOfBenefit.addItem.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
596. ExplanationOfBenefit.addItem.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
598. ExplanationOfBenefit.addItem.bodySite | |||||
Definition | Physical service site on the patient (limb, tooth, etc.). | ||||
Short | Anatomical location | ||||
Comments | For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. | ||||
Control | 0..1 | ||||
Binding | For example codes, see OralSiteCodes (example to http://hl7.org/fhir/ValueSet/tooth )The code for the teeth, quadrant, sextant and arch. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
600. ExplanationOfBenefit.addItem.subSite | |||||
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s). | ||||
Short | Anatomical sub-location | ||||
Control | 0..* | ||||
Binding | For example codes, see SurfaceCodes (example to http://hl7.org/fhir/ValueSet/surface )The code for the tooth surface and surface combinations. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows insurer to validate specific procedures. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
602. ExplanationOfBenefit.addItem.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
604. ExplanationOfBenefit.addItem.adjudication | |||||
Definition | The adjudication results. | ||||
Short | Added items adjudication | ||||
Control | 0..* | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
606. ExplanationOfBenefit.addItem.detail | |||||
Definition | The second-tier service adjudications for payor added services. | ||||
Short | Insurer added line items | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
608. ExplanationOfBenefit.addItem.detail.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
610. ExplanationOfBenefit.addItem.detail.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
612. ExplanationOfBenefit.addItem.detail.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
614. ExplanationOfBenefit.addItem.detail.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
Control | 1..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
616. ExplanationOfBenefit.addItem.detail.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Service/Product billing modifiers | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
618. ExplanationOfBenefit.addItem.detail.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
620. ExplanationOfBenefit.addItem.detail.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
622. ExplanationOfBenefit.addItem.detail.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
624. ExplanationOfBenefit.addItem.detail.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
626. ExplanationOfBenefit.addItem.detail.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
628. ExplanationOfBenefit.addItem.detail.adjudication | |||||
Definition | The adjudication results. | ||||
Short | Added items adjudication | ||||
Control | 0..* | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
630. ExplanationOfBenefit.addItem.detail.subDetail | |||||
Definition | The third-tier service adjudications for payor added services. | ||||
Short | Insurer added line items | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
632. ExplanationOfBenefit.addItem.detail.subDetail.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
634. ExplanationOfBenefit.addItem.detail.subDetail.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
636. ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
638. ExplanationOfBenefit.addItem.detail.subDetail.productOrService | |||||
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | ||||
Short | Billing, service, product, or drug code | ||||
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. | ||||
Control | 1..1 | ||||
Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls )Allowable service and product codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Necessary to state what was provided or done. | ||||
Alternate Names | Drug Code, Bill Code, Service Code | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
640. ExplanationOfBenefit.addItem.detail.subDetail.modifier | |||||
Definition | Item typification or modifiers codes to convey additional context for the product or service. | ||||
Short | Service/Product billing modifiers | ||||
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. | ||||
Control | 0..* | ||||
Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers )Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
642. ExplanationOfBenefit.addItem.detail.subDetail.quantity | |||||
Definition | The number of repetitions of a service or product. | ||||
Short | Count of products or services | ||||
Control | 0..1 | ||||
Type | Quantity(SimpleQuantity) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required when the product or service code does not convey the quantity provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
644. ExplanationOfBenefit.addItem.detail.subDetail.unitPrice | |||||
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. | ||||
Short | Fee, charge or cost per item | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The amount charged to the patient by the provider for a single unit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
646. ExplanationOfBenefit.addItem.detail.subDetail.factor | |||||
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
Short | Price scaling factor | ||||
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
648. ExplanationOfBenefit.addItem.detail.subDetail.net | |||||
Definition | The quantity times the unit price for an additional service or product or charge. | ||||
Short | Total item cost | ||||
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
650. ExplanationOfBenefit.addItem.detail.subDetail.noteNumber | |||||
Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
Short | Applicable note numbers | ||||
Control | 0..* | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
652. ExplanationOfBenefit.addItem.detail.subDetail.adjudication | |||||
Definition | The adjudication results. | ||||
Short | Added items adjudication | ||||
Control | 0..* | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
654. ExplanationOfBenefit.adjudication | |||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short | Header-level adjudication | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
656. ExplanationOfBenefit.adjudication.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
658. ExplanationOfBenefit.adjudication.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
660. ExplanationOfBenefit.adjudication.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
662. ExplanationOfBenefit.adjudication.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
664. ExplanationOfBenefit.adjudication.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 0..1 | ||||
Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason )Adjudication reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
666. ExplanationOfBenefit.adjudication.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
668. ExplanationOfBenefit.adjudication.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
670. ExplanationOfBenefit.adjudication:billingnetworkstatus | |||||
Slice Name | billingnetworkstatus | ||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short | Billing provider networking status | ||||
Comments | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101) | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
672. ExplanationOfBenefit.adjudication:billingnetworkstatus.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
674. ExplanationOfBenefit.adjudication:billingnetworkstatus.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
676. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
678. ExplanationOfBenefit.adjudication:billingnetworkstatus.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
680. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Payer Provider Network Status Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
682. ExplanationOfBenefit.adjudication:billingnetworkstatus.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
684. ExplanationOfBenefit.adjudication:billingnetworkstatus.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
686. ExplanationOfBenefit.adjudication:benefitpaymentstatus | |||||
Slice Name | benefitpaymentstatus | ||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short | Indicates the in network or out of network payment status of the claim. (142) | ||||
Comments | Indicates the in network or out of network payment status of the claim. (142) | ||||
Control | 1..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
688. ExplanationOfBenefit.adjudication:benefitpaymentstatus.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
690. ExplanationOfBenefit.adjudication:benefitpaymentstatus.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
692. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
694. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
696. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Payer Benefit Payment Status Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
698. ExplanationOfBenefit.adjudication:benefitpaymentstatus.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
700. ExplanationOfBenefit.adjudication:benefitpaymentstatus.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
702. ExplanationOfBenefit.adjudication:adjustmentreason | |||||
Slice Name | adjustmentreason | ||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short | Reason codes used to interpret the Non-Covered Amount (92) | ||||
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
704. ExplanationOfBenefit.adjudication:adjustmentreason.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
706. ExplanationOfBenefit.adjudication:adjustmentreason.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
708. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
710. ExplanationOfBenefit.adjudication:adjustmentreason.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
712. ExplanationOfBenefit.adjudication:adjustmentreason.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92) | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
714. ExplanationOfBenefit.adjudication:adjustmentreason.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
716. ExplanationOfBenefit.adjudication:adjustmentreason.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
718. ExplanationOfBenefit.adjudication:adjudicationamounttype | |||||
Slice Name | adjudicationamounttype | ||||
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. | ||||
Short | Claim level adjudication type and amount | ||||
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
720. ExplanationOfBenefit.adjudication:adjudicationamounttype.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
722. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
724. ExplanationOfBenefit.adjudication:adjudicationamounttype.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
726. ExplanationOfBenefit.adjudication:adjudicationamounttype.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to enable understanding of the context of the other information in the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
728. ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | |||||
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. | ||||
Short | Explanation of adjudication outcome | ||||
Comments | For example, may indicate that the funds for this benefit type have been exhausted. | ||||
Control | 0..1 | ||||
Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason )Adjudication reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To support understanding of variance from adjudication expectations. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
730. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount | |||||
Definition | Monetary amount associated with the category. | ||||
Short | Monetary amount | ||||
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. | ||||
Control | 1..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Most adjuciation categories convey a monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
732. ExplanationOfBenefit.adjudication:adjudicationamounttype.value | |||||
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. | ||||
Short | Non-monitary value | ||||
Comments | For example: eligible percentage or co-payment percentage. | ||||
Control | 0..1 | ||||
Type | decimal | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Some adjudication categories convey a percentage or a fixed value. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
734. ExplanationOfBenefit.total | |||||
Definition | Categorized monetary totals for the adjudication. | ||||
Short | Adjudication totals | ||||
Comments | Totals for amounts submitted, co-pays, benefits payable etc. | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | To provide the requestor with financial totals by category for the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.total . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
736. ExplanationOfBenefit.total.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
738. ExplanationOfBenefit.total.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
740. ExplanationOfBenefit.total.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
742. ExplanationOfBenefit.total.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from C4BB Total Category Discriminator Value Set (extensible to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Needed to convey the type of total provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
744. ExplanationOfBenefit.total.amount | |||||
Definition | Monetary total amount associated with the category. | ||||
Short | Financial total for the category | ||||
Comments | Total amount for each category (i.e., submitted, allowed, etc.) (148) | ||||
Control | 1..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Needed to convey the total monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
746. ExplanationOfBenefit.total:adjudicationamounttype | |||||
Slice Name | adjudicationamounttype | ||||
Definition | Categorized monetary totals for the adjudication. | ||||
Short | Total adjudication type and amount | ||||
Comments | Describes the various amount fields used when payers receive and adjudicate a claim. (187) | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | To provide the requestor with financial totals by category for the adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
748. ExplanationOfBenefit.total:adjudicationamounttype.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
750. ExplanationOfBenefit.total:adjudicationamounttype.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
752. ExplanationOfBenefit.total:adjudicationamounttype.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
754. ExplanationOfBenefit.total:adjudicationamounttype.category | |||||
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. | ||||
Short | Type of adjudication information | ||||
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from C4BB Adjudication Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Needed to convey the type of total provided. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
756. ExplanationOfBenefit.total:adjudicationamounttype.amount | |||||
Definition | Monetary total amount associated with the category. | ||||
Short | Financial total for the category | ||||
Control | 1..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Needed to convey the total monetary amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
758. ExplanationOfBenefit.payment | |||||
Definition | Payment details for the adjudication of the claim. | ||||
Short | Payment Details | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
760. ExplanationOfBenefit.payment.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
762. ExplanationOfBenefit.payment.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
764. ExplanationOfBenefit.payment.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
766. ExplanationOfBenefit.payment.type | |||||
Definition | Whether this represents partial or complete payment of the benefits payable. | ||||
Short | Partial or complete payment | ||||
Comments | Indicates whether the claim was paid or denied. (91) | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from C4BB Payer Claim Payment Status Code Value Set (required to http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To advise the requestor when the insurer believes all payments to have been completed. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
768. ExplanationOfBenefit.payment.adjustment | |||||
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. | ||||
Short | Payment adjustment for non-claim issues | ||||
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider. | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To advise the requestor of adjustments applied to the payment. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
770. ExplanationOfBenefit.payment.adjustmentReason | |||||
Definition | Reason for the payment adjustment. | ||||
Short | Explanation for the variance | ||||
Control | 0..1 | ||||
Binding | For example codes, see PaymentAdjustmentReasonCodes (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason )Payment Adjustment reason codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to clarify the monetary adjustment. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
772. ExplanationOfBenefit.payment.date | |||||
Definition | Estimated date the payment will be issued or the actual issue date of payment. | ||||
Short | Expected date of payment | ||||
Comments | The date the claim was paid. (107) | ||||
Control | 0..1 | ||||
Type | date | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | To advise the payee when payment can be expected. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
774. ExplanationOfBenefit.payment.amount | |||||
Definition | Benefits payable less any payment adjustment. | ||||
Short | Payable amount after adjustment | ||||
Control | 0..1 | ||||
Type | Money | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to provide the actual payment amount. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
776. ExplanationOfBenefit.payment.identifier | |||||
Definition | Issuer's unique identifier for the payment instrument. | ||||
Short | Business identifier for the payment | ||||
Comments | For example: EFT number or check number. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Enable the receiver to reconcile when payment received. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
778. ExplanationOfBenefit.formCode | |||||
Definition | A code for the form to be used for printing the content. | ||||
Short | Printed form identifier | ||||
Comments | May be needed to identify specific jurisdictional forms. | ||||
Control | 0..1 | ||||
Binding | For example codes, see Form Codes (example to http://hl7.org/fhir/ValueSet/forms )The forms codes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to specify the specific form used for producing output for this response. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
780. ExplanationOfBenefit.form | |||||
Definition | The actual form, by reference or inclusion, for printing the content or an EOB. | ||||
Short | Printed reference or actual form | ||||
Comments | Needed to permit insurers to include the actual form. | ||||
Control | 0..1 | ||||
Type | Attachment | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to include the specific form used for producing output for this response. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
782. ExplanationOfBenefit.processNote | |||||
Definition | A note that describes or explains adjudication results in a human readable form. | ||||
Short | Note concerning adjudication | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Provides the insurer specific textual explanations associated with the processing. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
784. ExplanationOfBenefit.processNote.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
786. ExplanationOfBenefit.processNote.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
788. ExplanationOfBenefit.processNote.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
790. ExplanationOfBenefit.processNote.number | |||||
Definition | A number to uniquely identify a note entry. | ||||
Short | Note instance identifier | ||||
Control | 0..1 | ||||
Type | positiveInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Necessary to provide a mechanism to link from adjudications. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
792. ExplanationOfBenefit.processNote.type | |||||
Definition | The business purpose of the note text. | ||||
Short | display | print | printoper | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from NoteType (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1 )The presentation types of notes. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | To convey the expectation for when the text is used. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
794. ExplanationOfBenefit.processNote.text | |||||
Definition | The explanation or description associated with the processing. | ||||
Short | Note explanatory text | ||||
Comments | Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181) | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Required to provide human readable explanation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
796. ExplanationOfBenefit.processNote.language | |||||
Definition | A code to define the language used in the text of the note. | ||||
Short | Language of the text | ||||
Comments | Only required if the language is different from the resource language. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Note text may vary from the resource defined language. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
798. ExplanationOfBenefit.benefitPeriod | |||||
Definition | The term of the benefits documented in this response. | ||||
Short | When the benefits are applicable | ||||
Comments | Not applicable when use=claim. | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
800. ExplanationOfBenefit.benefitBalance | |||||
Definition | Balance by Benefit Category. | ||||
Short | Balance by Benefit Category | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
802. ExplanationOfBenefit.benefitBalance.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
804. ExplanationOfBenefit.benefitBalance.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
806. ExplanationOfBenefit.benefitBalance.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
808. ExplanationOfBenefit.benefitBalance.category | |||||
Definition | Code to identify the general type of benefits under which products and services are provided. | ||||
Short | Benefit classification | ||||
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. | ||||
Control | 1..1 | ||||
Binding | For example codes, see BenefitCategoryCodes (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory )Benefit categories such as: oral, medical, vision, oral-basic etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to convey the category of service or product for which eligibility is sought. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
810. ExplanationOfBenefit.benefitBalance.excluded | |||||
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage. | ||||
Short | Excluded from the plan | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to identify items that are specifically excluded from the coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
812. ExplanationOfBenefit.benefitBalance.name | |||||
Definition | A short name or tag for the benefit. | ||||
Short | Short name for the benefit | ||||
Comments | For example: MED01, or DENT2. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Required to align with other plan names. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
814. ExplanationOfBenefit.benefitBalance.description | |||||
Definition | A richer description of the benefit or services covered. | ||||
Short | Description of the benefit or services covered | ||||
Comments | For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed for human readable reference. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
816. ExplanationOfBenefit.benefitBalance.network | |||||
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers. | ||||
Short | In or out of network | ||||
Control | 0..1 | ||||
Binding | For example codes, see NetworkTypeCodes (example to http://hl7.org/fhir/ValueSet/benefit-network )Code to classify in or out of network services. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed as in or out of network providers are treated differently under the coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
818. ExplanationOfBenefit.benefitBalance.unit | |||||
Definition | Indicates if the benefits apply to an individual or to the family. | ||||
Short | Individual or family | ||||
Control | 0..1 | ||||
Binding | For example codes, see UnitTypeCodes (example to http://hl7.org/fhir/ValueSet/benefit-unit )Unit covered/serviced - individual or family. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed for the understanding of the benefits. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
820. ExplanationOfBenefit.benefitBalance.term | |||||
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. | ||||
Short | Annual or lifetime | ||||
Control | 0..1 | ||||
Binding | For example codes, see BenefitTermCodes (example to http://hl7.org/fhir/ValueSet/benefit-term )Coverage unit - annual, lifetime. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed for the understanding of the benefits. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
822. ExplanationOfBenefit.benefitBalance.financial | |||||
Definition | Benefits Used to date. | ||||
Short | Benefit Summary | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
824. ExplanationOfBenefit.benefitBalance.financial.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
826. ExplanationOfBenefit.benefitBalance.financial.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
828. ExplanationOfBenefit.benefitBalance.financial.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
830. ExplanationOfBenefit.benefitBalance.financial.type | |||||
Definition | Classification of benefit being provided. | ||||
Short | Benefit classification | ||||
Comments | For example: deductible, visits, benefit amount. | ||||
Control | 1..1 | ||||
Binding | For example codes, see BenefitTypeCodes (example to http://hl7.org/fhir/ValueSet/benefit-type )Deductable, visits, co-pay, etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to convey the nature of the benefit. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
832. ExplanationOfBenefit.benefitBalance.financial.allowed[x] | |||||
Definition | The quantity of the benefit which is permitted under the coverage. | ||||
Short | Benefits allowed | ||||
Control | 0..1 | ||||
Type | Choice of: unsignedInt, string, Money | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to convey the benefits offered under the coverage. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
834. ExplanationOfBenefit.benefitBalance.financial.used[x] | |||||
Definition | The quantity of the benefit which have been consumed to date. | ||||
Short | Benefits used | ||||
Control | 0..1 | ||||
Type | Choice of: unsignedInt, Money | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Needed to convey the benefits consumed to date. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |