CARIN Blue Button Implementation Guide CI Build

CARIN Blue Button, CARIN Alliance - CI build for vesion 0.1.36-DRAFT). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

EOB Comprehensive mapping

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Slice L0 L1 L2 L3 L4 Flag Cardinality DataType /
Value Set
Description
ExplanationOfBenefit TU DomainResource Explanation of Benefit resource
ExplanationOfBenefit Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
ExplanationOfBenefit identifier 1..* Identifier Business Identifier for the resource
ExplanationOfBenefit status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
ExplanationOfBenefit status ExplanationOfBenefitStatus (Required)
ExplanationOfBenefit type Σ 1..1 CodeableConcept Category or discipline
ExplanationOfBenefit type Claim Type Codes (Extensible)
ExplanationOfBenefit subtype 0..1 CodeableConcept More granular claim type
ExplanationOfBenefit subtype Example Claim SubType Codes (Example)
ExplanationOfBenefit use Σ 1..1 code claim | preauthorization | predetermination
ExplanationOfBenefit use Use (Required)
ExplanationOfBenefit patient--> Σ 1..1 Reference(Patient) The recipient of the products and services
ExplanationOfBenefit billablePeriod Σ 0..1 Period Relevant time frame for the claim
ExplanationOfBenefit created Σ 1..1 dateTime Response creation date
ExplanationOfBenefit enterer--> 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
ExplanationOfBenefit insurer--> Σ 1..1 Reference(Organization) Party responsible for reimbursement
ExplanationOfBenefit provider--> Σ 1..1 Reference(PractionerRole) Party responsible for the claim
ExplanationOfBenefit priority 0..1 CodeableConcept Desired processing urgency
ExplanationOfBenefit priority ProcessPriority 
ExplanationOfBenefit fundsReservedRequested 0..1 CodeableConcept For whom to reserve funds
ExplanationOfBenefit fundsReservedRequested FundsReserve (Example)
ExplanationOfBenefit fundsReserve 0..1 CodeableConcept Funds reserved status
ExplanationOfBenefit fundsReserve FundsReserve (Example)
ExplanationOfBenefit related 0..* BackboneElement Prior or corollary claims
ExplanationOfBenefit related claim--> 0..1 Reference(Claim) Reference to the related claim
ExplanationOfBenefit related relationship 0..1 CodeableConcept How the reference claim is related
ExplanationOfBenefit related relationship Example Related Claim Relationship Codes (Example)
ExplanationOfBenefit related reference 0..1 Identifier File or case reference
ExplanationOfBenefit prescription--> 0..1 Reference(MedicationRequest| VisionPrescription) Prescription authorizing services or products
ExplanationOfBenefit originalPrescription--> 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
ExplanationOfBenefit payee 0..1 BackboneElement Recipient of benefits payable
ExplanationOfBenefit payee type 0..1 CodeableConcept Category of recipient
ExplanationOfBenefit payee type PayeeType (Example)
ExplanationOfBenefit payee party--> 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
ExplanationOfBenefit referral--> 0..1 Reference(ServiceRequest) Treatment Referral
ExplanationOfBenefit facility--> 0..1 Reference(Location) Servicing Facility
ExplanationOfBenefit claim--> 0..1 Reference(Claim) Claim reference
ExplanationOfBenefit claimResponse--> 0..1 Reference(ClaimResponse) Claim response reference
ExplanationOfBenefit outcome Σ 1..1 code queued | complete | error | partial
ExplanationOfBenefit outcome Claim Processing Codes (Required)
ExplanationOfBenefit disposition 0..1 string Disposition Message
ExplanationOfBenefit preAuthRef 0..* string Preauthorization reference
ExplanationOfBenefit preAuthRefPeriod 0..* Period Preauthorization in-effect period
ExplanationOfBenefit careTeam 0..* BackboneElement Care Team members
ExplanationOfBenefit careTeam sequence 1..1 positiveInt Order of care team
ExplanationOfBenefit careTeam provider--> 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
ExplanationOfBenefit careTeam responsible 0..1 boolean Indicator of the lead practitioner
ExplanationOfBenefit careTeam role 0..1 CodeableConcept Function within the team
ExplanationOfBenefit careTeam role Claim Care Team Role Codes (Example)
ExplanationOfBenefit careTeam qualification 0..1 CodeableConcept Practitioner credential or specialization
ExplanationOfBenefit careTeam qualification Example Provider Qualification Codes (Example)
ExplanationOfBenefit supportingInfo 1..* BackboneElement Supporting information
ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier
ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information
ExplanationOfBenefit supportingInfo category Claim Information Category Codes (Example)
ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information
ExplanationOfBenefit supportingInfo code Exception Codes (Example)
ExplanationOfBenefit supportingInfo timing 0..1 When it occurred
ExplanationOfBenefit supportingInfo timing timingDate date
ExplanationOfBenefit supportingInfo timing timingPeriod Period
ExplanationOfBenefit supportingInfo value 1..1 Data to be provided
ExplanationOfBenefit supportingInfo value valueBoolean boolean
ExplanationOfBenefit supportingInfo value valueString string
ExplanationOfBenefit supportingInfo value valueQuantity Quantity
ExplanationOfBenefit supportingInfo value valueAttachment Attachment
ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)
ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information
ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes (Example)
ExplanationOfBenefit diagnosis 0..* BackboneElement Pertinent diagnosis information
ExplanationOfBenefit diagnosis sequence 1..1 positiveInt Diagnosis instance identifier
ExplanationOfBenefit diagnosis diagnosis 1..1 CodeableConcept Nature of illness or problem
ExplanationOfBenefit diagnosis diagnosis ICD-10 Codes (Example)
ExplanationOfBenefit diagnosis diagnosis Reference(Condition)
ExplanationOfBenefit diagnosis type 0..* CodeableConcept Timing or nature of the diagnosis
ExplanationOfBenefit diagnosis type Example Diagnosis Type Codes (Example)
ExplanationOfBenefit diagnosis onAdmission 0..1 CodeableConcept Present on admission
ExplanationOfBenefit diagnosis onAdmission Example Diagnosis on Admission Codes (Example)
ExplanationOfBenefit diagnosis packageCode 0..1 CodeableConcept Package billing code
ExplanationOfBenefit diagnosis packageCode Example Diagnosis Related Group Codes (Example)
ExplanationOfBenefit procedure 0..* BackboneElement Clinical procedures performed
ExplanationOfBenefit procedure sequence 1..1 positiveInt Procedure instance identifier
ExplanationOfBenefit procedure type 0..* CodeableConcept Category of Procedure
ExplanationOfBenefit procedure type Example Procedure Type Codes (Example)
ExplanationOfBenefit procedure date 0..1 dateTime When the procedure was performed
ExplanationOfBenefit procedure procedure 1..1 Specific clinical procedure
ExplanationOfBenefit procedure procedure ICD-10 Procedure Codes (Example)
ExplanationOfBenefit procedure procedure procedureCodeableConcept CodeableConcept
ExplanationOfBenefit procedure procedure procedureReference--> Reference(Procedure)
ExplanationOfBenefit procedure udi 0..* Reference(Device) Unique device identifier
ExplanationOfBenefit precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
ExplanationOfBenefit insurance Σ 1..* BackboneElement Patient insurance information
ExplanationOfBenefit insurance focal Σ 1..1 boolean Coverage to be used for adjudication
ExplanationOfBenefit insurance coverage--> Σ 1..1 Reference(Coverage) Insurance information
ExplanationOfBenefit insurance coverage--> Σ 1..1 Reference(Coverage) Insurance information
ExplanationOfBenefit insurance preAuthRef 0..* string Prior authorization reference number
ExplanationOfBenefit accident 0..1 BackboneElement Details of the event
ExplanationOfBenefit accident date 0..1 date When the incident occurred
ExplanationOfBenefit accident type 0..1 CodeableConcept The nature of the accident
ExplanationOfBenefit accident type V3 Value SetActIncidentCode (Extensible)
ExplanationOfBenefit accident location 0..1 Where the event occurred
ExplanationOfBenefit accident location locationAddress Address
ExplanationOfBenefit accident location locationReference Reference(Location)
ExplanationOfBenefit item 0..* BackboneElement Product or service provided
ExplanationOfBenefit item sequence 1..1 positiveInt Item instance identifier
ExplanationOfBenefit item careTeamSequence 0..* positiveInt Applicable care team members
ExplanationOfBenefit item diagnosisSequence 0..* positiveInt Applicable diagnoses
ExplanationOfBenefit item procedureSequence 0..* positiveInt Applicable procedures
ExplanationOfBenefit item informationSequence 0..* positiveInt Applicable exception and supporting information
ExplanationOfBenefit item revenue 0..1 CodeableConcept Revenue or cost center code
ExplanationOfBenefit item revenue Example Revenue Center Codes (Example)
ExplanationOfBenefit item category 0..1 CodeableConcept Benefit classification
ExplanationOfBenefit item category Benefit Category Codes (Example)
ExplanationOfBenefit item productOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit item productOrService USCLS Codes (Example)
ExplanationOfBenefit item modifier 0..* CodeableConcept Product or service billing modifiers
ExplanationOfBenefit item modifier Modifier type Codes (Example)
ExplanationOfBenefit item programCode 0..* CodeableConcept Program the product or service is provided under
ExplanationOfBenefit item programCode Example Program Reason Codes (Example)
ExplanationOfBenefit item serviced 0..1 Date or dates of service or product delivery
ExplanationOfBenefit item serviced servicedDate date Date or dates of service or product delivery
ExplanationOfBenefit item serviced servicedPeriod Period Date or dates of service or product delivery
ExplanationOfBenefit item location 0..1 Place of service or where product was supplied
ExplanationOfBenefit item location Example Service Place Codes (Example)
ExplanationOfBenefit item location locationCodeableConcept CodeableConcept
ExplanationOfBenefit item location locationAddress Address
ExplanationOfBenefit item location locationReference--> Reference(Location)
ExplanationOfBenefit item quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit item unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit item factor 0..1 decimal Price scaling factor
ExplanationOfBenefit item net 0..1 Money Total item cost
ExplanationOfBenefit item udi--> 0..* Reference(Device) Unique device identifier
ExplanationOfBenefit item bodySite 0..1 CodeableConcept Anatomical location
ExplanationOfBenefit item bodySite Oral Site Codes (Example)
ExplanationOfBenefit item subSite 0..* CodeableConcept Anatomical sub-location
ExplanationOfBenefit item subSite Surface Codes (Example)
ExplanationOfBenefit item encounter--> 0..* Reference(Encounter) Encounters related to this billed item
ExplanationOfBenefit item noteNumber 0..* positiveInt Applicable note numbers
ExplanationOfBenefit item adjudication 0..* BackboneElement Adjudication details
ExplanationOfBenefit item adjudication category 1..1 CodeableConcept Type of adjudication information
ExplanationOfBenefit item adjudication category Adjudication Value Codes (Example)
ExplanationOfBenefit item adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome
ExplanationOfBenefit item adjudication reason Adjudication Reason Codes (Example)
ExplanationOfBenefit item adjudication amount 0..1 Money Monetary amount
ExplanationOfBenefit item adjudication value 0..1 decimal Non-monitary value
ExplanationOfBenefit item detail value 0..* BackboneElement Additional items
ExplanationOfBenefit item detail sequence 1..1 positiveInt Product or service provided
ExplanationOfBenefit item detail revenue 0..1 CodeableConcept Revenue or cost center code
ExplanationOfBenefit item detail revenue Example Revenue Center Codes (Example)
ExplanationOfBenefit item detail category 0..1 CodeableConcept Benefit classification
ExplanationOfBenefit item detail category Benefit Category Codes (Example)
ExplanationOfBenefit item detail productOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit item detail productOrService USCLS Codes (Example)
ExplanationOfBenefit item detail modifier 0..* CodeableConcept Service/Product billing modifiers
ExplanationOfBenefit item detail modifier Modifier type Codes (Example)
ExplanationOfBenefit item detail programCode 0..* CodeableConcept Program the product or service is provided under
ExplanationOfBenefit item detail programCode Example Program Reason Codes (Example)
ExplanationOfBenefit item detail quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit item detail unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit item detail factor 0..1 decimal Price scaling factor
ExplanationOfBenefit item detail net 0..1 Money Total item cost
ExplanationOfBenefit item detail udi--> 0..* Reference(Device) Unique device identifier
ExplanationOfBenefit item detail noteNumber 0..* positiveInt Applicable note numbers
ExplanationOfBenefit item detail adjudication 0..* see adjudication Detail level adjudication details
ExplanationOfBenefit item detail subDetail 0..* BackboneElement Additional items
ExplanationOfBenefit item detail subDetail sequence 1..1 positiveInt Product or service provided
ExplanationOfBenefit item detail subDetail revenue 0..1 CodeableConcept Revenue or cost center code
ExplanationOfBenefit item detail subDetail revenue Example Revenue Center Codes (Example)
ExplanationOfBenefit item detail subDetail category 0..1 CodeableConcept Benefit classification
ExplanationOfBenefit item detail subDetail category Benefit Category Codes (Example)
ExplanationOfBenefit item detail subDetail productOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit item detail subDetail productOrService USCLS Codes (Example)
ExplanationOfBenefit item detail subDetail modifier 0..* CodeableConcept Service/Product billing modifiers
ExplanationOfBenefit item detail subDetail modifier Modifier type Codes (Example)
ExplanationOfBenefit item detail subDetail programCode 0..* CodeableConcept Program the product or service is provided under
ExplanationOfBenefit item detail subDetail programCode Example Program Reason Codes (Example)
ExplanationOfBenefit item detail subDetail quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit item detail subDetail unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit item detail subDetail factor 0..1 decimal Price scaling factor
ExplanationOfBenefit item detail subDetail net 0..1 Money Total item cost
ExplanationOfBenefit item detail subDetail udi 0..* Reference(Device) Unique device identifier
ExplanationOfBenefit item detail subDetail note 0..* positiveInt Applicable note numbers
ExplanationOfBenefit item detail subDetail adjudication 0..* see adjudication Subdetail level adjudication details
ExplanationOfBenefit additem 0..* BackboneElement Insurer added line items
ExplanationOfBenefit additem itemSequence 0..* positiveInt Item sequence number
ExplanationOfBenefit additem detailSequence 0..* positiveInt Detail sequence number
ExplanationOfBenefit additem subDetailSequence 0..* positiveInt Subdetail sequence number
ExplanationOfBenefit additem provider--> 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
ExplanationOfBenefit additem productOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit additem productOrService USCLS Codes (Example)
ExplanationOfBenefit additem modifier 0..* CodeableConcept Service/Product billing modifiers
ExplanationOfBenefit additem modifier Modifier type Codes (Example)
ExplanationOfBenefit additem programCode 0..* CodeableConcept Program the product or service is provided under
ExplanationOfBenefit additem programCode Example Program Reason Codes (Example)
ExplanationOfBenefit additem serviced[x] 0..1 Date or dates of service or product delivery
ExplanationOfBenefit additem serviced[x] servicedDate date
ExplanationOfBenefit additem serviced[x] servicedPeriod Period
ExplanationOfBenefit additem location[x] 0..1 Place of service or where product was supplied
ExplanationOfBenefit additem location[x] Example Service Place Codes (Example)
ExplanationOfBenefit additem location[x] locationCodeableConcept CodeableConcept
ExplanationOfBenefit additem location[x] locationAddress Address
ExplanationOfBenefit additem location[x] locationReference--> Reference(Location)
ExplanationOfBenefit additem quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit additem unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit additem factor 0..1 decimal Price scaling factor
ExplanationOfBenefit additem net 0..1 Money Total item cost
ExplanationOfBenefit additem bodySite 0..1 CodeableConcept Anatomical location
ExplanationOfBenefit additem bodySite Oral Site Codes (Example)
ExplanationOfBenefit additem subSite 0..* CodeableConcept Anatomical sub-location
ExplanationOfBenefit additem subSite Surface Codes (Example)
ExplanationOfBenefit additem noteNumber 0..* positiveInt Applicable note numbers
ExplanationOfBenefit additem adjudication 0..* see adjudication Added items adjudication
ExplanationOfBenefit additem detail 0..* BackboneElement Insurer added line items
ExplanationOfBenefit additem detail productOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit additem detail productOrService USCLS Codes (Example)
ExplanationOfBenefit additem detail modifier 0..* CodeableConcept Service/Product billing modifiers
ExplanationOfBenefit additem detail modifier Modifier type Codes (Example)
ExplanationOfBenefit additem detail quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit additem detail unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit additem detail factor 0..1 decimal Price scaling factor
ExplanationOfBenefit additem detail net 0..1 Money Total item cost
ExplanationOfBenefit additem detail noteNumber 0..* positiveInt Applicable note numbers
ExplanationOfBenefit additem detail adjudication 0..* see adjudication Added items adjudication
ExplanationOfBenefit additem detail subDetail 0..* BackboneElement Insurer added line items
ExplanationOfBenefit additem detail subDetail ProductOrService 1..1 CodeableConcept Billing, service, product, or drug code
ExplanationOfBenefit additem detail subDetail ProductOrService USCLS Codes (Example)
ExplanationOfBenefit additem detail subDetail modifier 0..* CodeableConcept Service/Product billing modifiers
ExplanationOfBenefit additem detail subDetail modifier Modifier type Codes (Example)
ExplanationOfBenefit additem detail subDetail quantity 0..1 SimpleQuantity Count of products or services
ExplanationOfBenefit additem detail subDetail unitPrice 0..1 Money Fee, charge or cost per item
ExplanationOfBenefit additem detail subDetail factor 0..1 decimal Price scaling factor
ExplanationOfBenefit additem detail subDetail net 0..1 Money Total item cost
ExplanationOfBenefit additem detail subDetail noteNumber 0..* positiveInt Applicable note numbers
ExplanationOfBenefit additem detail subDetail adjudication 0..* see adjudication Added items adjudication
ExplanationOfBenefit adjudication 0..* see adjudication Header-level adjudication
ExplanationOfBenefit total Σ 1..* BackboneElement Adjudication totals
ExplanationOfBenefit total category Σ 1..1 CodeableConcept Type of adjudication information
ExplanationOfBenefit total category Adjudication Value Codes (Example)
ExplanationOfBenefit total amount Σ 1..1 Money Financial total for the category
ExplanationOfBenefit payment 0..1 BackboneElement Payment Details
ExplanationOfBenefit payment type 0..1 CodeableConcept Partial or complete payment
ExplanationOfBenefit payment type Example Payment Type Codes (Example)
ExplanationOfBenefit payment adjustment 0..1 Money Payment adjustment for non-claim issues
ExplanationOfBenefit payment adjustmentReason 0..1 CodeableConcept Explanation for the variance
ExplanationOfBenefit payment adjustmentReason Payment Adjustment Reason Codes (Example)
ExplanationOfBenefit payment date 0..1 date Expected date of payment
ExplanationOfBenefit payment amount 0..1 Money Payable amount after adjustment
ExplanationOfBenefit payment identifier 0..1 Identifier Business identifier for the payment
ExplanationOfBenefit formCode 0..1 CodeableConcept Printed form identifier
ExplanationOfBenefit formCode Forms (Example)
ExplanationOfBenefit form 0..1 Attachment Printed reference or actual form
ExplanationOfBenefit processNote 0..* BackboneElement Note concerning adjudication
ExplanationOfBenefit processNote number 0..1 positiveInt Note instance identifier
ExplanationOfBenefit processNote type 0..1 code display | print | printoper
ExplanationOfBenefit processNote type NoteType (Required)
ExplanationOfBenefit processNote text 0..1 string Note explanatory text
ExplanationOfBenefit processNote language 0..1 CodeableConcept Language of the text
ExplanationOfBenefit processNote language Common Languages (Preferred but limited to AllLanguages)
ExplanationOfBenefit benefitPeriod 0..1 Period When the benefits are applicable
ExplanationOfBenefit benefitBalance 0..* BackboneElement Balance by Benefit Category
ExplanationOfBenefit benefitBalance category 1..1 CodeableConcept Benefit classification
ExplanationOfBenefit benefitBalance category Benefit Category Codes (Example)
ExplanationOfBenefit benefitBalance excluded 0..1 boolean Excluded from the plan
ExplanationOfBenefit benefitBalance name 0..1 string Short name for the benefit
ExplanationOfBenefit benefitBalance description 0..1 string Description of the benefit or services covered
ExplanationOfBenefit benefitBalance network 0..1 CodeableConcept In or out of network
ExplanationOfBenefit benefitBalance network Network Type Codes (Example)
ExplanationOfBenefit benefitBalance unit 0..1 CodeableConcept Individual or family
ExplanationOfBenefit benefitBalance unit Unit Type Codes (Example)
ExplanationOfBenefit benefitBalance term 0..1 CodeableConcept Annual or lifetime
ExplanationOfBenefit benefitBalance term Benefit Term Codes (Example)
ExplanationOfBenefit benefitBalance financial 0..* BackboneElement Benefit Summary
ExplanationOfBenefit benefitBalance financial type 1..1 CodeableConcept Benefit classification
ExplanationOfBenefit benefitBalance financial type Benefit Type Codes (Example)
ExplanationOfBenefit benefitBalance allowed 0..1 Benefits allowed
ExplanationOfBenefit benefitBalance allowed allowedUnsignedInt unsignedInt
ExplanationOfBenefit benefitBalance allowed allowedString string
ExplanationOfBenefit benefitBalance allowed allowedMoney Money
ExplanationOfBenefit benefitBalance used 0..1 Benefits used
ExplanationOfBenefit benefitBalance used usedUnsignedInt unsignedInt
ExplanationOfBenefit benefitBalance used usedMoney Money
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