CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit | Version: 2.1.0 | |||
Standards status: Trial-use | Computable Name: C4BBExplanationOfBenefit |
Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four concrete EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician
CPCDS modified the concept of primary payer to other payer to accommodate situations when multiple prior payers are involved. Each amount paid by the other payer should be listed separately.
There are two paths to get to the Patient Resource and the data elements represented inside the Patient Resource: EOB.patient(Patient) and EOB.insurance.coverage(Coverage).beneficiary(Patient)
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | 0..* | ExplanationOfBenefit | This is an abstractprofile. Childprofiles: C4BBExplanationOfBenefitInpatientInstitutionalBasis, C4BBExplanationOfBenefitOralBasis, C4BBExplanationOfBenefitOutpatientInstitutionalBasis, C4BBExplanationOfBenefitPharmacyBasis, C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource | |
meta | S | 1..1 | Meta | Metadata about the resource |
lastUpdated | S | 1..1 | instant | When the resource version last changed |
profile | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |
identifier:All Slices | Content/Rules for all slices | |||
type | 0..1 | CodeableConcept | Description of identifier | |
identifier:uniqueclaimid | S | 1..1 | Identifier | Unique Claim Identifier |
type | 1..1 | CodeableConcept | Description of identifier Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
value | S | 1..1 | string | Unique Claim Identifier |
status | S | 1..1 | code | active | cancelled | draft | entered-in-error |
type | S | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
use | S | 1..1 | code | claim | preauthorization | predetermination Required Pattern: claim |
patient | S | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | S | 1..1 | Period | Relevant time frame for the claim |
start | S | 1..1 | dateTime | Starting time with inclusive boundary |
end | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | |
created | 1..1 | dateTime | Response creation date | |
insurer | S | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
related | S | 0..* | BackboneElement | Prior or corollary claims |
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) |
reference | S | 1..1 | Identifier | File or case reference |
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required |
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) |
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference |
outcome | S | 1..1 | code | queued | complete | error | partial |
careTeam | S | 0..* | BackboneElement | Care Team members |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization |
role | S | 0..1 | CodeableConcept | Function within the team |
supportingInfo | S | 0..* | BackboneElement | Supporting information |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |
insurance | SC | 1..* | BackboneElement | Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true |
focal | S | 1..1 | boolean | Coverage to be used for adjudication |
coverage | S | 1..1 | Reference(C4BB Coverage) | Insurance information |
item | S | 1..* | BackboneElement | Product or service provided |
sequence | S | 1..1 | positiveInt | Item instance identifier |
noteNumber | S | 0..* | positiveInt | Applicable note numbers |
adjudication | ||||
category | S | 1..1 | CodeableConcept | Type of adjudication information |
payment | S | 0..1 | BackboneElement | Payment Details |
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required) |
date | 0..1 | date | Expected date of payment | |
processNote | S | 0..* | BackboneElement | Note concerning adjudication |
text | 0..1 | string | Note explanatory text | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes from this IG | |
ExplanationOfBenefit.payee.type | required | C4BBPayeeTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType from this IG | |
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-insurance-focal | error | ExplanationOfBenefit.insurance | EOB.insurance: at most one with focal = true : select (focal = true).count() < 2 | |
EOB-payee-other-type-requires-party | error | ExplanationOfBenefit.payee | Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | 0..* | ExplanationOfBenefit | This is an abstractprofile. Childprofiles: C4BBExplanationOfBenefitInpatientInstitutionalBasis, C4BBExplanationOfBenefitOralBasis, C4BBExplanationOfBenefitOutpatientInstitutionalBasis, C4BBExplanationOfBenefitPharmacyBasis, C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource | |
meta | SΣ | 1..1 | Meta | Metadata about the resource |
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed |
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |
identifier:All Slices | Content/Rules for all slices | |||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. |
identifier:uniqueclaimid | S | 1..1 | Identifier | Unique Claim Identifier |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
value | SΣ | 1..1 | string | Unique Claim Identifier Example General: 123456 |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) |
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim |
patient | SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | SΣ | 1..1 | Period | Relevant time frame for the claim |
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary |
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
created | Σ | 1..1 | dateTime | Response creation date |
insurer | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | SΣ | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
related | S | 0..* | BackboneElement | Prior or corollary claims |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) |
reference | S | 1..1 | Identifier | File or case reference |
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) |
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference |
outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
careTeam | S | 0..* | BackboneElement | Care Team members |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization |
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. |
supportingInfo | S | 0..* | BackboneElement | Supporting information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |
insurance | SΣC | 1..* | BackboneElement | Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | SΣ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information |
item | S | 1..* | BackboneElement | Product or service provided |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | S | 1..1 | positiveInt | Item instance identifier |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
noteNumber | S | 0..* | positiveInt | Applicable note numbers |
adjudication | 0..* | BackboneElement | Adjudication details | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
payment | S | 0..1 | BackboneElement | Payment Details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required) |
date | 0..1 | date | Expected date of payment | |
processNote | S | 0..* | BackboneElement | Note concerning adjudication |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
text | 0..1 | string | Note explanatory text | |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uchttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes from this IG | |
ExplanationOfBenefit.payee.type | required | C4BBPayeeTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType from this IG | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard | |
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-insurance-focal | error | ExplanationOfBenefit.insurance | EOB.insurance: at most one with focal = true : select (focal = true).count() < 2 | |
EOB-payee-other-type-requires-party | error | ExplanationOfBenefit.payee | Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | 0..* | ExplanationOfBenefit | This is an abstractprofile. Childprofiles: C4BBExplanationOfBenefitInpatientInstitutionalBasis, C4BBExplanationOfBenefitOralBasis, C4BBExplanationOfBenefitOutpatientInstitutionalBasis, C4BBExplanationOfBenefitPharmacyBasis, C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | SΣ | 1..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
identifier:uniqueclaimid | S | 1..1 | Identifier | Unique Claim Identifier | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | SΣ | 1..1 | string | Unique Claim Identifier Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim | ||||
patient | SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services | ||||
billablePeriod | SΣ | 1..1 | Period | Relevant time frame for the claim | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement | ||||
provider | SΣ | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
related | S | 0..* | BackboneElement | Prior or corollary claims | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) | ||||
reference | S | 1..1 | Identifier | File or case reference | ||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) | ||||
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference | ||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
facility | 0..1 | Reference(Location) | Servicing Facility | |||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |||||
careTeam | S | 0..* | BackboneElement | Care Team members | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Order of care team | |||||
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | ||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | ||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
supportingInfo | S | 0..* | BackboneElement | Supporting information | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |||||
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
timing[x] | 0..1 | When it occurred | ||||||
timingDate | date | |||||||
timingPeriod | Period | |||||||
value[x] | 0..1 | Data to be provided | ||||||
valueBoolean | boolean | |||||||
valueString | string | |||||||
valueQuantity | Quantity | |||||||
valueAttachment | Attachment | |||||||
valueReference | Reference(Resource) | |||||||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | SΣC | 1..* | BackboneElement | Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
focal | SΣ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 0..1 | BackboneElement | Details of the event | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
date | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
item | S | 1..* | BackboneElement | Product or service provided | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | S | 1..1 | positiveInt | Item instance identifier | ||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Product 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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||
noteNumber | S | 0..* | positiveInt | Applicable note numbers | ||||
adjudication | 0..* | BackboneElement | Adjudication details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
detail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
addItem | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 0..* | positiveInt | Item sequence number | |||||
detailSequence | 0..* | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
detail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
subDetail | 0..* | BackboneElement | Insurer added line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
factor | 0..1 | decimal | Price scaling factor | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | S | 0..1 | BackboneElement | Payment Details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required) | ||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
form | 0..1 | Attachment | Printed reference or actual form | |||||
processNote | S | 0..* | BackboneElement | Note concerning adjudication | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
number | 0..1 | positiveInt | Note instance identifier | |||||
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
text | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
financial | 0..* | BackboneElement | Benefit Summary | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
ExplanationOfBenefit.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
ExplanationOfBenefit.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
ExplanationOfBenefit.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ExplanationOfBenefit.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uchttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.type | required | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
ExplanationOfBenefit.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes from this IG | ||||
ExplanationOfBenefit.payee.type | required | C4BBPayeeTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType from this IG | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ExplanationOfBenefit.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode from this IG | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | ||||
ExplanationOfBenefit.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard | ||||
ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
EOB-insurance-focal | error | ExplanationOfBenefit.insurance | EOB.insurance: at most one with focal = true : select (focal = true).count() < 2 | |
EOB-payee-other-type-requires-party | error | ExplanationOfBenefit.payee | Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists() |