Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft Australia flag

Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions

Resource Profile: ADHA Record of Claim against PBS or RPBS

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-explanationofbenefit-medicare-pbs-1 Version: 1.0.0
Active as of 2024-09-12 Computable Name: ADHAExplanationofBenefitPBS

Copyright/Legal: Copyright © 2023 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to define a representation of a record of a claim against the Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) for the electronic exchange of digital health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend ExplanationOfBenefit that are supported.

This profile is designed to set an ExplanationOfBenefit standard for:

  • Query for a record of a PBS or RPBS item claim associated with a patient
  • Record or update a PBS or RPBS item claim associated with a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

  • In an exchange with the My Health Record system references to a MedicationRequest resource will be contained.

Usage:

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... identifier S 1..* Identifier Business Identifier for the resource
... status S 1..1 code active | cancelled | draft | entered-in-error
Fixed Value: active
... type S 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
... use S 1..1 code claim | preauthorization | predetermination
Fixed Value: claim
... patient SC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... created SC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... insurer SC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider S 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... outcome S 1..1 code queued | complete | error | partial
Fixed Value: complete
... insurance S 1..1 BackboneElement Patient insurance information
.... focal S 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage S 1..1 Reference(Coverage) Medicare or Veteran card information
... item S 1..1 BackboneElement Product or service provided
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... category S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
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://pbs.gov.au/code/item
.... serviced[x] S 1..1 date, Period Date or dates of service or product delivery
.... quantity S 0..1 SimpleQuantity Count of products or services

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for the resource
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
... subType S 1..1 CodeableConcept More granular claim type
Binding: Australian Medicare Benefit and Claim Category . (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Fixed Value: claim
... patient SΣC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... created SΣC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... insurer SΣC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider SΣ 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


Fixed Value: complete
... insurance SΣ 1..1 BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage SΣ 1..1 Reference(Coverage) Medicare or Veteran card information
... item S 1..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
Fixed Value: 1
.... category S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
Binding: USCLSCodes (example): Allowable service and product codes.


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://pbs.gov.au/code/item
.... serviced[x] S 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... quantity S 0..1 SimpleQuantity Count of products or services

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typeextensiblePattern: pharmacy
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredFixed Value: complete
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.item.productOrServiceexamplePattern: null
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for the resource
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept More granular claim type
Binding: Australian Medicare Benefit and Claim Category . (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Fixed Value: claim
... patient SΣC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider SΣ 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... 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 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 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1 Identifier File or case reference
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... 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 0..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | 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.


Fixed Value: complete
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam 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 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 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 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... 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 SΣ 1..1 BackboneElement Patient insurance 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
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage SΣ 1..1 Reference(Coverage) Medicare or Veteran card 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..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
Fixed Value: 1
.... 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 S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
Binding: USCLSCodes (example): Allowable service and product codes.


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://pbs.gov.au/code/item
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... 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
.... 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] S 1..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 S 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 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 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 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 0..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... 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 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

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

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

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

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

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

.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typeextensiblePattern: pharmacy
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
http://hl7.org/fhir/ValueSet/related-claim-relationship
from the FHIR Standard
ExplanationOfBenefit.prescription.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredFixed Value: complete
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
http://hl7.org/fhir/ValueSet/claim-careteamrole
from the FHIR Standard
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
http://hl7.org/fhir/ValueSet/provider-qualification
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
http://hl7.org/fhir/ValueSet/icd-10
from the FHIR Standard
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
http://hl7.org/fhir/ValueSet/ex-diagnosistype
from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
from the FHIR Standard
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.item.productOrServiceexamplePattern: null
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10

Differential View

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... identifier S 1..* Identifier Business Identifier for the resource
... status S 1..1 code active | cancelled | draft | entered-in-error
Fixed Value: active
... type S 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
... use S 1..1 code claim | preauthorization | predetermination
Fixed Value: claim
... patient SC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... created SC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... insurer SC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider S 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... outcome S 1..1 code queued | complete | error | partial
Fixed Value: complete
... insurance S 1..1 BackboneElement Patient insurance information
.... focal S 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage S 1..1 Reference(Coverage) Medicare or Veteran card information
... item S 1..1 BackboneElement Product or service provided
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... category S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
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://pbs.gov.au/code/item
.... serviced[x] S 1..1 date, Period Date or dates of service or product delivery
.... quantity S 0..1 SimpleQuantity Count of products or services

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for the resource
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
... subType S 1..1 CodeableConcept More granular claim type
Binding: Australian Medicare Benefit and Claim Category . (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Fixed Value: claim
... patient SΣC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... created SΣC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... insurer SΣC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider SΣ 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


Fixed Value: complete
... insurance SΣ 1..1 BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage SΣ 1..1 Reference(Coverage) Medicare or Veteran card information
... item S 1..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
Fixed Value: 1
.... category S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
Binding: USCLSCodes (example): Allowable service and product codes.


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://pbs.gov.au/code/item
.... serviced[x] S 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... quantity S 0..1 SimpleQuantity Count of products or services

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typeextensiblePattern: pharmacy
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredFixed Value: complete
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.item.productOrServiceexamplePattern: null
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..* ExplanationOfBenefit Record of Claim against PBS or RPBS
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for the resource
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept More granular claim type
Binding: Australian Medicare Benefit and Claim Category . (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Fixed Value: claim
... patient SΣC 1..1 Reference(ADHA Core Patient) The recipient of the products and services
inv-dh-eob-01: At least reference or a valid identifier shall be present
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣC 1..1 dateTime Response creation date
inv-dh-eob-03: Date shall be at least to day
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣC 1..1 Reference(ADHA Core Organization) Australian Government department that subsidises the benefits scheme
inv-dh-eob-02: At least reference or a valid identifier shall be present
... provider SΣ 1..1 Reference(ADHA Core PractitionerRole) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (example)
... 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 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 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1 Identifier File or case reference
... prescription S 1..1 Reference(ADHA PBS Claim Item) Prescription authorizing services or products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... 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 0..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | 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.


Fixed Value: complete
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam 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 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 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 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... 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 SΣ 1..1 BackboneElement Patient insurance 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
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage SΣ 1..1 Reference(Coverage) Medicare or Veteran card 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..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
Fixed Value: 1
.... 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 S 1..1 CodeableConcept Benefit classification
Binding: Australian Medicare Benefit and Claim Category . (extensible)
.... productOrService S 1..1 CodeableConcept PBS Billing code
Binding: USCLSCodes (example): Allowable service and product codes.


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://pbs.gov.au/code/item
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... 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
.... 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] S 1..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 S 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 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 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 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 0..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... 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 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

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

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

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

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

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

.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typeextensiblePattern: pharmacy
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshipexampleExampleRelatedClaimRelationshipCodes
http://hl7.org/fhir/ValueSet/related-claim-relationship
from the FHIR Standard
ExplanationOfBenefit.prescription.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
ExplanationOfBenefit.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredFixed Value: complete
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.roleexampleClaimCareTeamRoleCodes
http://hl7.org/fhir/ValueSet/claim-careteamrole
from the FHIR Standard
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
http://hl7.org/fhir/ValueSet/provider-qualification
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]exampleICD-10Codes
http://hl7.org/fhir/ValueSet/icd-10
from the FHIR Standard
ExplanationOfBenefit.diagnosis.typeexampleExampleDiagnosisTypeCodes
http://hl7.org/fhir/ValueSet/ex-diagnosistype
from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
from the FHIR Standard
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.categoryextensibleAustralianMedicareBenefitAndClaimCategory .
https://healthterminologies.gov.au/fhir/ValueSet/australian-medicare-benefit-claim-category-1
ExplanationOfBenefit.item.productOrServiceexamplePattern: null
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-eob-01errorExplanationOfBenefit.patientAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-02errorExplanationOfBenefit.insurerAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-eob-03errorExplanationOfBenefit.createdDate shall be at least to day
: toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
identifier token SHALL The business identifier of the Explanation of Benefit ExplanationOfBenefit.identifier
patient:identifier token SHALL The reference to the patient ExplanationOfBenefit.patient.identifier
type token SHALL Classification of the record - for indexing/retrieval ExplanationOfBenefit.type
subType token SHALL Classification of the record using funding scheme - for indexing/retrieval ExplanationOfBenefit.subType
created date SHALL The creation date for the EOB ExplanationOfBenefit.created
status token SHALL Status of the instance ExplanationOfBenefit.status

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all claims for a patient using the patient:identifier search parameter:

    GET [base]/ExplanationOfBenefit?patient:identifier={system|}[code]

    Example:

     GET [base]/ExplanationOfBenefit?patient:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437

    Implementation Notes: Fetches a bundle of all ExplanationOfBenefit resources for the specified patient (how to search by :identifier)

  2. SHALL support searching using the identifier search parameter:

    GET [base]/ExplanationOfBenefit?identifier={system|}[code]

    Example:

     GET [base]/ExplanationOfBenefit?identifier=urn:ietf:rfc:3986|urn:uuid:44a8f148-f5f7-447c-9e68-a9f06635ab6c

    Implementation Notes: Fetches a bundle containing any ExplanationOfBenefit resources matching the identifier (how to search by token)

  3. SHALL support searching using the combination patient:identifier and type and status search parameter:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/ExplanationOfBenefit?patient:identifier={system|}[code]&type={system|}[code]&status={system|}[code]

    Example:

     GET [base]/ExplanationOfBenefit?patient:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&type=http://terminology.hl7.org/CodeSystem/claim-type|pharmacy&status=active

    Implementation Notes: Fetches a bundle of all active ExplanationOfBenefit resources with the type of "Pharmacy" for the specified patient (how to search by :identifier and how to search by token)

  4. SHALL support searching using the combination patient:identifier and subType and status search parameter:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/ExplanationOfBenefit?patient:identifier={system|}[code]&subType={system|}[code]&status={system|}[code]

    Example:

     GET [base]/ExplanationOfBenefit?patient:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&subType=https://healthterminologies.gov.au/fhir/CodeSystem/australian-benefit-payment-category-1|pbs&status=active

    Implementation Notes: Fetches a bundle of all active ExplanationOfBenefit resources with the subType of pbs (PBS) for the specified patient (how to search by :identifier and how to search by token)

  5. SHALL support searching using the combination of the patient:identifier and created and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/ExplanationOfBenefit?patient:identifier={system|}[code]&created=[date]&status={system|}[code]

    Example:

     GET [base]/ExplanationOfBenefit?patient:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&created=ge2013-03-14&status=active

    Implementation Notes: Fetches a bundle of all active ExplanationOfBenefit resources for the specified patient that have a created date greater than or equal to 21st Jan 2013. (how to search by :identifier and how to search by date)