CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
2.0.0 - STU 2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Pharmacy

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy Version: 2.0.0
Active as of 2023-08-02 Computable Name: C4BBExplanationOfBenefitPharmacy

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies. The claims data is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program)

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts and amount types of the claim are to be provided in EOB.total.  The in network or out of network payment status of the claim are to be provided in EOB.supportingInfo.
  • ExplanationOfBenefit.item.productOrService:  values are NDC Codes when Compound Code (MapID 78) = 0 or 1.  When the Compound Code = 2, productOrService = "compound" and map the ingredient to ExplanationOfBenefit.item.detail.productOrService
  • ExplanationOfBenefit.item.productOrService and item.detail.productOrService: Payers shall provide an 11-digit NDC. For additional information, reference the Other useful Information in the HL7 Terminology Authority - External Terminologies - NDC Confluence site, https://confluence.hl7.org/pages/viewpage.action?pageId=97453858
  • ExplanationOfBenefit.item.quantity:  populate for all Compound Code values.  When the Compound Code = 2, if available, map the ingredient to ExplanationOfBenefit.item.detail.quantity
  • ExplanationOfBenefit.item.adjudication.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient).  The eligible amount - the member liability is the payment amount to the provider (paidtoprovider). 
  • ExplanationOfBenefit.total.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient).  The eligible amount - the member liability is the payment amount to the provider (paidtoprovider). 
  • ExplanationOfBenefit.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the claim
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... identifier S1..*IdentifierBusiness Identifier for the resource
... type 1..1CodeableConceptCategory or discipline
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
... created S1..1dateTimeResponse creation date
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
... Slices for supportingInfo 4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:refillsAuthorized 1..1BackboneElementNumber or refills authorized by prescriber
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
... item
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
.... detail S0..*BackboneElementAdditional items
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... quantity S0..1SimpleQuantityCount of products or services
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount S1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-versionerrorExplanationOfBenefitPharmacy 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-Pharmacy|2.0.'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... meta SĪ£1..1MetaMetadata about the resource
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
... created SĪ£1..1dateTimeResponse creation date
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*BackboneElementCare Team members
EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner
EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
... Slices for supportingInfo S4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:refillsAuthorized S1..1BackboneElementNumber or refills authorized by prescriber
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
... item S1..*BackboneElementProduct or service provided
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... quantity S0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
.... detail S0..*BackboneElementAdditional items
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... quantity S0..1SimpleQuantityCount of products or services
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount SĪ£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S0..1dateExpected date of payment
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: pharmacy
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:dayssupply.categoryextensiblePattern: dayssupply
ExplanationOfBenefit.supportingInfo:dawcode.categoryextensiblePattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:refillNum.categoryextensiblePattern: refillnum
ExplanationOfBenefit.supportingInfo:refillsAuthorized.categoryextensiblePattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:brandgenericindicator.categoryextensiblePattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.categoryextensiblePattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:compoundcode.categoryextensiblePattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.categoryexamplePattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-versionerrorExplanationOfBenefitPharmacy 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-Pharmacy|2.0.'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... id Ī£0..1idLogical id of this artifact
... meta SĪ£1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies where the resource comes from
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Ī£0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Ī£0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier S1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
..... period Ī£0..1PeriodTime period when id is/was valid for use
..... assigner Ī£0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end Ī£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SC0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SC0..*BackboneElementCare Team members
EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner
EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:refillsAuthorized S1..1BackboneElementNumber or refills authorized by prescriber
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1dateWhen it occurred
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

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

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


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

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


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


.... serviced[x] S1..1dateDate or dates of service or product delivery
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail S0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


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


..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

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

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


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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


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


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

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount SĪ£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text S0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

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

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

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: pharmacy
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dayssupply.categoryextensiblePattern: dayssupply
ExplanationOfBenefit.supportingInfo:dayssupply.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:dayssupply.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dawcode.categoryextensiblePattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:dawcode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillNum.categoryextensiblePattern: refillnum
ExplanationOfBenefit.supportingInfo:refillNum.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:refillNum.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.categoryextensiblePattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:refillsAuthorized.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:brandgenericindicator.categoryextensiblePattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:rxoriginCode.categoryextensiblePattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:rxoriginCode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:compoundcode.categoryextensiblePattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.supportingInfo:compoundcode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:rejectreason.categoryexamplePattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 16 elements (7 nested mandatory elements)
Must-Support: 48 elements

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

Differential View

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... identifier S1..*IdentifierBusiness Identifier for the resource
... type 1..1CodeableConceptCategory or discipline
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
... created S1..1dateTimeResponse creation date
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
... Slices for supportingInfo 4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:refillsAuthorized 1..1BackboneElementNumber or refills authorized by prescriber
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
... item
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
.... detail S0..*BackboneElementAdditional items
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... quantity S0..1SimpleQuantityCount of products or services
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount S1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-versionerrorExplanationOfBenefitPharmacy 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-Pharmacy|2.0.'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... meta SĪ£1..1MetaMetadata about the resource
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
... created SĪ£1..1dateTimeResponse creation date
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*BackboneElementCare Team members
EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner
EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
... Slices for supportingInfo S4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:refillsAuthorized S1..1BackboneElementNumber or refills authorized by prescriber
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
..... value[x] S1..1QuantityData to be provided
.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
... item S1..*BackboneElementProduct or service provided
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... quantity S0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
.... detail S0..*BackboneElementAdditional items
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... quantity S0..1SimpleQuantityCount of products or services
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount SĪ£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S0..1dateExpected date of payment
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: pharmacy
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:dayssupply.categoryextensiblePattern: dayssupply
ExplanationOfBenefit.supportingInfo:dawcode.categoryextensiblePattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:refillNum.categoryextensiblePattern: refillnum
ExplanationOfBenefit.supportingInfo:refillsAuthorized.categoryextensiblePattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:brandgenericindicator.categoryextensiblePattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.categoryextensiblePattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:compoundcode.categoryextensiblePattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.categoryexamplePattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-versionerrorExplanationOfBenefitPharmacy 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-Pharmacy|2.0.'))

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
... id Ī£0..1idLogical id of this artifact
... meta SĪ£1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies where the resource comes from
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Ī£0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Ī£0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier S1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
..... period Ī£0..1PeriodTime period when id is/was valid for use
..... assigner Ī£0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: pharmacy
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end Ī£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SC0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SC0..*BackboneElementCare Team members
EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner
EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S4..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:dayssupply S1..1BackboneElementDays supply
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dayssupply
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:dawcode S1..1BackboneElementDispense and written product selection code
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dawcode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:refillNum S1..1BackboneElementThe number fill of the claim dispensed supply
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillnum
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:refillsAuthorized S1..1BackboneElementNumber or refills authorized by prescriber
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: refillsauthorized
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] S1..1QuantityData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:brandgenericindicator S0..1BackboneElementPlan reported brand or generic drug indicator
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: brandgenericindicator
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Brand Generic Indicator Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:rxoriginCode S0..1BackboneElementPrescription origin code
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxorigincode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Prescription Origin Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1dateWhen it occurred
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:compoundcode S0..1BackboneElementCode indicating whether or not the prescription is a compound
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: compoundcode
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: NCPDP Compound Code Value Set (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

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

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


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

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: NDC or Compound Value Set (required)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


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


.... serviced[x] S1..1dateDate or dates of service or product delivery
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S1..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S1..*BackboneElementLine level adjudication type and amount
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:rejectreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: rejectreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: NCPDP Reject Code Value Set (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail S0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: National Drug Code (NDC) Value Set (required)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


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


..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

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

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


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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


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


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

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider networking status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount SĪ£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text S0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

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

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

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: pharmacy
ExplanationOfBenefit.subTypeexampleExampleClaimSubTypeCodes
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimPharmacyTeamRole
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dayssupply.categoryextensiblePattern: dayssupply
ExplanationOfBenefit.supportingInfo:dayssupply.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:dayssupply.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dawcode.categoryextensiblePattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.coderequiredNCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:dawcode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillNum.categoryextensiblePattern: refillnum
ExplanationOfBenefit.supportingInfo:refillNum.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:refillNum.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.categoryextensiblePattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:refillsAuthorized.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:brandgenericindicator.categoryextensiblePattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.coderequiredNCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:rxoriginCode.categoryextensiblePattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.coderequiredNCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:rxoriginCode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:compoundcode.categoryextensiblePattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.coderequiredNCPDPCompoundCode
ExplanationOfBenefit.supportingInfo:compoundcode.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredFDANDCOrCompound
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:rejectreason.categoryexamplePattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reasonrequiredNCPDPRejectCode
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServicerequiredFDANationalDrugCode
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
EOB-pharm-careTeam-organizationerrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitionererrorExplanationOfBenefit.careTeamPharmacy EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 16 elements (7 nested mandatory elements)
Must-Support: 48 elements

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

 

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