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 Inpatient Facility mapping

Slice L0 L1 L2 L3 L4 Cardinality **“DataType / **        
Value Set” Description MapID CARIN CPCDS Data Element Name “Cardinality /              
DataType” Value Set Comments Working Note                  
ExplanationOfBenefit DomainResource Explanation of Benefit resource                  
ExplanationOfBenefit Elements defined in Ancestors:id,meta,implicitRules,language,text,contained,extension,modifierExtension                    
ExplanationOfBenefit identifier 0..* Identifier Business Identifier for the resource 35, 111, 112 Claim unique identifier, Claim adjusted from identifier, Claim adjusted to identifier          
ExplanationOfBenefit status 1..1 code active | cancelled | draft | entered-in-error 140 “Claim processing status code          
value = active | cancelled | entered-in-error                    
ExplanationOfBenefit status ExplanationOfBenefitStatus(Required)                  
ExplanationOfBenefit type 1..1 CodeableConcept Category or discipline 16 Claim type values: Inpatient Facility        
ExplanationOfBenefit type Claim Type Codes(Extensible) 16 Claim type http://terminology.hl7.org/CodeSystem/claim-type These define the Claims profiles (there is also a Coverage profile).          
ExplanationOfBenefit subtype 0..1 CodeableConcept More granular claim type 15 [1..1] (CD-CHAR(14)) values: Inpatient Facility - Acute | Inpatient Facility - Non-Acute CPCDS: Removed from scope      
ExplanationOfBenefit subtype Example Claim SubType Codes(Example) 15 [1..1] (CD-CHAR(14))              
ExplanationOfBenefit use 1..1 code claim | preauthorization | predetermination New value = claim          
ExplanationOfBenefit use Use(Required)                  
ExplanationOfBenefit patient--> 1..1 Reference(Patient) The recipient of the products and services Ref (1) Member id [1.1] (CHAR) Contained      
ExplanationOfBenefit patient--> 1..1 Reference(Patient) The recipient of the products and services Ref (109) Patient account number [1.1] (CHAR) Contained      
ExplanationOfBenefit patient--> 1..1 Reference(Patient) The recipient of the products and services Ref (110) Medical record number [1.1] (CHAR) Contained      
ExplanationOfBenefit billablePeriod 0..1 Period Relevant time frame for the claim 18, 19 Member admission date, Member discharge date [1..1] (TS8) “period.start      
period.end”                      
ExplanationOfBenefit created 1..1 dateTime Response creation date new [1..1] (TS8)          
ExplanationOfBenefit enterer--> 0..1 Reference(Practitioner|PractitionerRole) Author of the claim              
ExplanationOfBenefit insurer--> 1..1 Reference(Organization) Party responsible for reimbursement Ref (2, 5) Claim payer Identifier Organization.identifier Same as insurance.coverage.organization. Party responsible for reimbursing the provider.      
ExplanationOfBenefit provider--> 1..1 Reference(PractionerRole) Party responsible for the claim Ref (89) [0..1] (CD-CHAR(5)) Organization.address.zipcode        
ExplanationOfBenefit provider--> 1..1 Reference(Organization) Party responsible for the claim Ref (94) Claim billing provider NPI [1..1] CHAR(10) Organization.identifier      
ExplanationOfBenefit priority 0..1 CodeableConcept Desired processing urgency              
ExplanationOfBenefit priority ProcessPriority(Example)                  
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 120 Claim payee type code        
ExplanationOfBenefit payee type PayeeType(Example) 120 Claim payee type code subscriber | provider | other          
ExplanationOfBenefit payee party--> 0..1 Reference(PractitionerRole| Patient) Recipient reference 121 Claim payee        
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 1..1 code queued | complete | error | partial New value = complete          
ExplanationOfBenefit outcome Claim Processing Codes(Required) New                
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 Ref (93, 95, 96, 99) Provider NPIs [1..1] CHAR(10) PractionerRole.practioner --> Practioner.identifier PractionerRole.code = attending | performing | pcp | referring  
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)                
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 101 reference supportinginfo.sequence rule      
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 101 value = ‘billingnetworkcontractingstatus’      
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 101            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 101 Claim billing provider network status      
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo code Exception Codes(Example) 101 Claim billing provider network status values: contracted | non-contracted        
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingDate date            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingPeriod Period            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueBoolean boolean            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueString string            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
billingnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 101 reference supportinginfo.sequence rule      
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 101 value = ‘attendingnetworkcontractingstatus’      
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 101            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 101 Claim attending provider network status      
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo code Exception Codes(Example) 101 Claim attending provider network status values: contracted | non-contracted        
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingDate date            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingPeriod Period            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueBoolean boolean            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueString string            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
attendingnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 101 reference supportinginfo.sequence rule      
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 101 value = ‘referringnetworkcontractingstatus’      
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 101            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 101 Claim Referring Physican Network Status      
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo code Exception Codes(Example) 101 Claim Referring Physican Network Status values: contracted | non-contracted        
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingDate date            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo timing timingPeriod Period            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueBoolean boolean            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueString string            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
referringnetworkcontractingstatus ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
claimrecvddate ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
claimrecvddate ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 88 reference supportinginfo.sequence rule      
claimrecvddate ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 88 value = ‘clmrecvddate’      
claimrecvddate ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
claimrecvddate ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information          
claimrecvddate ExplanationOfBenefit supportingInfo code Exception Codes(Example)              
claimrecvddate ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
claimrecvddate ExplanationOfBenefit supportingInfo timing timingDate date 88 Claim received date [1..1] (TS8)      
claimrecvddate ExplanationOfBenefit supportingInfo timing timingPeriod Period            
claimrecvddate ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
claimrecvddate ExplanationOfBenefit supportingInfo value valueBoolean boolean            
claimrecvddate ExplanationOfBenefit supportingInfo value valueString string            
claimrecvddate ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
claimrecvddate ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
claimrecvddate ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
claimrecvddate ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
claimrecvddate ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
DerrivedTypeOfService ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 34 reference supportinginfo.sequence rule      
DerrivedTypeOfService ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 34 value = ‘Derived Type of Service’      
DerrivedTypeOfService ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 34            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 34 Type of service [1.1] (CD-CHAR(5)) “coding.system = url of code system  
coding.code = the code value”                      
DerrivedTypeOfService ExplanationOfBenefit supportingInfo code Exception Codes(Example) 34 Type of service [1.1] (CD-CHAR(5))        
DerrivedTypeOfService ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo timing timingDate date            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo timing timingPeriod Period            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value valueBoolean boolean            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value valueString string            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
DerrivedTypeOfService ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
DerrivedTypeOfService ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
TypeofBill ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information 17          
TypeofBill ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 17 reference supportinginfo.sequence rule      
TypeofBill ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 17 value = ‘Type of Bill’      
TypeofBill ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 17            
TypeofBill ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 17 [1..1] (CD-CHAR(3)) UB-04 “coding.system = url of code system    
coding.code = the code value” Not applicable for CARIN                    
TypeofBill ExplanationOfBenefit supportingInfo code Exception Codes(Example) 17 [1..1] (CD-CHAR(3)) UB-04 Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill. Not applicable for CARIN      
TypeofBill ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
TypeofBill ExplanationOfBenefit supportingInfo timing timingDate date            
TypeofBill ExplanationOfBenefit supportingInfo timing timingPeriod Period            
TypeofBill ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
TypeofBill ExplanationOfBenefit supportingInfo value valueBoolean boolean            
TypeofBill ExplanationOfBenefit supportingInfo value valueString string            
TypeofBill ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
TypeofBill ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
TypeofBill ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
TypeofBill ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
TypeofBill ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
tob-typeoffacility ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information 114          
tob-typeoffacility ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 114 reference supportinginfo.sequence rule      
tob-typeoffacility ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 114 value = ‘tob-typeoffacility’      
tob-typeoffacility ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 114            
tob-typeoffacility ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 114 Claim bill facility type code [1..1] (CD-CHAR(1)) UB-04 “coding.system = url of code system  
coding.code = the code value”                      
tob-typeoffacility ExplanationOfBenefit supportingInfo code Exception Codes(Example) 114 Claim bill facility type code [1..1] (CD-CHAR(1)) UB-04 Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill.      
tob-typeoffacility ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
tob-typeoffacility ExplanationOfBenefit supportingInfo timing timingDate date            
tob-typeoffacility ExplanationOfBenefit supportingInfo timing timingPeriod Period            
tob-typeoffacility ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
tob-typeoffacility ExplanationOfBenefit supportingInfo value valueBoolean boolean            
tob-typeoffacility ExplanationOfBenefit supportingInfo value valueString string            
tob-typeoffacility ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
tob-typeoffacility ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
tob-typeoffacility ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
tob-typeoffacility ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
tob-typeoffacility ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
tob-billclassification ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information 115          
tob-billclassification ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 115 reference supportinginfo.sequence rule      
tob-billclassification ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 115 value = ‘tob-billclassification’      
tob-billclassification ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 115            
tob-billclassification ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 115 Claim service classification type code [1..1] (CD-CHAR(1)) UB-04 “coding.system = url of code system  
coding.code = the code value”                      
tob-billclassification ExplanationOfBenefit supportingInfo code Exception Codes(Example) 115 Claim service classification type code [1..1] (CD-CHAR(1)) UB-04 Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill.      
tob-billclassification ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
tob-billclassification ExplanationOfBenefit supportingInfo timing timingDate date            
tob-billclassification ExplanationOfBenefit supportingInfo timing timingPeriod Period            
tob-billclassification ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
tob-billclassification ExplanationOfBenefit supportingInfo value valueBoolean boolean            
tob-billclassification ExplanationOfBenefit supportingInfo value valueString string            
tob-billclassification ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
tob-billclassification ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
tob-billclassification ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
tob-billclassification ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
tob-billclassification ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
tob-frequency ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information 116          
tob-frequency ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 116 reference supportinginfo.sequence rule      
tob-frequency ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 116 value = ‘tob-frequency’      
tob-frequency ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 116            
tob-frequency ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 116 Claim frequency code [1..1] (CD-CHAR(1)) UB-04 “coding.system = url of code system  
coding.code = the code value”                      
tob-frequency ExplanationOfBenefit supportingInfo code Exception Codes(Example) 116 Claim frequency code [1..1] (CD-CHAR(1)) UB-04 Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill.      
tob-frequency ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
tob-frequency ExplanationOfBenefit supportingInfo timing timingDate date            
tob-frequency ExplanationOfBenefit supportingInfo timing timingPeriod Period            
tob-frequency ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
tob-frequency ExplanationOfBenefit supportingInfo value valueBoolean boolean            
tob-frequency ExplanationOfBenefit supportingInfo value valueString string            
tob-frequency ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
tob-frequency ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
tob-frequency ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
tob-frequency ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
tob-frequency ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
admsrc ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
admsrc ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 13 reference supportinginfo.sequence rule      
admsrc ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 13 value = ‘admsrc’      
admsrc ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 13            
admsrc ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 13 Claim source inpatient admission code [1..1] (CD-CHAR(2))UB-04 “coding.system = url of code system  
coding.code = the code value”                      
admsrc ExplanationOfBenefit supportingInfo code Exception Codes(Example) 13 Claim source inpatient admission code [1..1] (CD-CHAR(2))UB-04        
admsrc ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
admsrc ExplanationOfBenefit supportingInfo timing timingDate date            
admsrc ExplanationOfBenefit supportingInfo timing timingPeriod Period            
admsrc ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
admsrc ExplanationOfBenefit supportingInfo value valueBoolean boolean            
admsrc ExplanationOfBenefit supportingInfo value valueString string            
admsrc ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
admsrc ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
admsrc ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
admsrc ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
admsrc ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
admtype ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
admtype ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 14 reference supportinginfo.sequence rule      
admtype ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 14 value = ‘admtype’      
admtype ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 14            
admtype ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 14 Claim inpatient admission type code [1.1] (CD-CHAR(2)) “coding.system = url of code system  
coding.code = the code value”                      
admtype ExplanationOfBenefit supportingInfo code Exception Codes(Example) 14 Claim inpatient admission type code [1.1] (CD-CHAR(2))        
admtype ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
admtype ExplanationOfBenefit supportingInfo timing timingDate date            
admtype ExplanationOfBenefit supportingInfo timing timingPeriod Period            
admtype ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
admtype ExplanationOfBenefit supportingInfo value valueBoolean boolean            
admtype ExplanationOfBenefit supportingInfo value valueString string            
admtype ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
admtype ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
admtype ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
admtype ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
admtype ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
discharge-status ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
discharge-status ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 117 reference supportinginfo.sequence rule      
discharge-status ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 117 value = ‘discharge-status’      
discharge-status ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 117            
discharge-status ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 117 Patient discharge status code [1.1] (CD-CHAR(2)) “coding.system = url of code system  
coding.code = the code value”                      
discharge-status ExplanationOfBenefit supportingInfo code Exception Codes(Example) 117 Patient discharge status code [1.1] (CD-CHAR(2)) UB04 (Form Locator 17)      
discharge-status ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
discharge-status ExplanationOfBenefit supportingInfo timing timingDate date            
discharge-status ExplanationOfBenefit supportingInfo timing timingPeriod Period            
discharge-status ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
discharge-status ExplanationOfBenefit supportingInfo value valueBoolean boolean            
discharge-status ExplanationOfBenefit supportingInfo value valueString string            
discharge-status ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
discharge-status ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
discharge-status ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
discharge-status ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
discharge-status ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
DRG ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
DRG ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 33, 32, 113 reference supportinginfo.sequence rule      
DRG ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 33, 32, 113 value = ‘DRG’      
DRG ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 33, 32, 113            
DRG ExplanationOfBenefit supportingInfo code 1..1 CodeableConcept Classification of the supplied information 33, 32, 113 Claim diagnosis related group (DRG), including the code system, the DRG version and the code value [1..1] (CD-CHAR(4))DRG2 “coding.system = url of the code system  
coding.version = DRG Version Code                      
coding.code = the code value; e.g. ‘090’                      
coding.display = concept associated with the code; e.g. ‘CONCUSSION WITHOUT CC/MCC’”                      
DRG ExplanationOfBenefit supportingInfo code Exception Codes(Example) 33, 32, 113 [1..1] (CD-CHAR(4))DRG3          
DRG ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
DRG ExplanationOfBenefit supportingInfo timing timingDate date            
DRG ExplanationOfBenefit supportingInfo timing timingPeriod Period            
DRG ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
DRG ExplanationOfBenefit supportingInfo value valueBoolean boolean            
DRG ExplanationOfBenefit supportingInfo value valueString string            
DRG ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
DRG ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
DRG ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
DRG ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
DRG ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
PlaceOfService ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
PlaceOfService ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 46 reference supportinginfo.sequence rule      
PlaceOfService ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 46 value = ‘Place of Service’      
PlaceOfService ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example) 46            
PlaceOfService ExplanationOfBenefit supportingInfo code 1..1 CodeableConcept Type of information 46 Place of service code [1..1] (CD-CHAR(2)) “coding.system = url of the code system  
coding.code = the code value”                      
PlaceOfService ExplanationOfBenefit supportingInfo code Exception Codes(Example) 46 Place of service code [1..1] (CD-CHAR(2))        
PlaceOfService ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
PlaceOfService ExplanationOfBenefit supportingInfo timing timingDate date            
PlaceOfService ExplanationOfBenefit supportingInfo timing timingPeriod Period            
PlaceOfService ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
PlaceOfService ExplanationOfBenefit supportingInfo value valueBoolean boolean            
PlaceOfService ExplanationOfBenefit supportingInfo value valueString string            
PlaceOfService ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
PlaceOfService ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
PlaceOfService ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
PlaceOfService ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
PlaceOfService ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
ExplanationOfBenefit diagnosis 0..* BackboneElement Pertinent diagnosis information              
ExplanationOfBenefit diagnosis sequence 1..1 positiveInt Diagnosis instance identifier New reference diagnosis.sequence rule        
ExplanationOfBenefit diagnosis diagnosis 1..1 CodeableConcept Nature of illness or problem 6, 7, 8, 21, 22, 23, 30, 31, 145 Diagnosis Code, Description [1..1] (CD-ICD-9) or (CD-!CD-10) “coding.code = the code value    
i.e. example 250.02 for ICD-9                      
i.e. example E11.65 for ICD-10                      
coding.system = url of code system                      
i.e. example ICD-9 / ICD-10                      
text = string representation of the diagnosis” CPCDS does not include MapID #31, Patient Reason for Visit Code                    
ExplanationOfBenefit diagnosis diagnosis 1..1 ICD-10 Codes(Example) 6, 7, 8, 21, 22, 23, 30, 31, 145 Diagnosis dode [1..1] (CD-ICD-9) or (CD-!CD-10) “ICD-9 or      
ICD-10                      
(Required)”                      
ExplanationOfBenefit diagnosis diagnosis Reference(Condition)                
ExplanationOfBenefit diagnosis type 0..1 CodeableConcept Timing or nature of the diagnosis New (6, 7, 8, 21, 22, 23) [1..1] (CD) “Diagnosis Type      
principal | secondary                      
                     
ExplanationOfBenefit diagnosis type Example Diagnosis Type Codes(Example) New (6, 7, 8, 21, 22, 23) [1..1] (CD) “Diagnosis Type          
principal | secondary                      
Value Set TBD                    
ExplanationOfBenefit diagnosis type 0..1 CodeableConcept Timing or nature of the diagnosis New (30, 31) [1..1] (CD) “Diagnosis Type      
e-code                      
value = ‘y’ forICD-9 diagnosis codes beginning with ‘E’ or ‘V’ or ICD-10 diagnosis codes in the range V00.* through Y99.                    
ExplanationOfBenefit diagnosis type Example Diagnosis Type Codes(Example) New (30, 31) [1..1] (CD) “Diagnosis Type          
e-code                      
Value Set TBD                    
ExplanationOfBenefit diagnosis onAdmission 0..1 CodeableConcept Present on admission 28, 29 Present on admission [1..1] CHAR ( 1 ) “coding.system = url of the code system    
coding.code = the code value”                      
ExplanationOfBenefit diagnosis onAdmission Example Diagnosis on Admission Codes(Example) 28, 29 Present on admission [1..1] CHAR ( 1 )          
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 “New          
(9, 11, 24, 26)” reference procedure.sequence rule                    
ExplanationOfBenefit procedure type 0..* CodeableConcept Category of Procedure “New          
(9, 11, 24, 26)” “principal | secondary1-24                    
Procedure Type                    
ExplanationOfBenefit procedure type Example Procedure Type Codes(Example) “New              
(9, 11, 24, 26)”                      
ExplanationOfBenefit procedure date 0..1 dateTime When the procedure was performed 10,12, 25, 27 Procedure date [1..1] (TS8)      
ExplanationOfBenefit procedure procedure 1..1 Specific clinical procedure 9, 11, 24, 26, 146 ICD Procedure Code [1..1] (CD) (CD-ICD-9) or (CD-ICD-10) “coding.code = the code value      
text = string representation of the procedure”                      
ExplanationOfBenefit procedure procedure ICD-10 Procedure Codes(Example) 9, 11, 24, 26, 146 ICD Procedure Code [1..1] (CD) (CD-ICD-9) or (CD-ICD-10)        
coding.system = url of code system                      
                     
ExplanationOfBenefit procedure procedure procedureCodeableConcept CodeableConcept ICD-10 Procedure Codes(Example) 9, 11, 24, 26 ICD Procedure Code [1..1] (CD) (CD-ICD-9) or (CD-ICD-10)    
coding.system = url of code system                      
                     
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 1..1 BackboneElement Patient insurance information              
ExplanationOfBenefit insurance focal 1..1 boolean Coverage to be used for adjudication New value = true        
ExplanationOfBenefit insurance coverage--> 1..1 Reference(Coverage) Insurance information Ref (3) Contained        
ExplanationOfBenefit insurance coverage--> 1..1 Reference(Coverage) Insurance information Ref (2) Claim payer Identifier Coverage.payer--> Organization.identifier Contained (The Plan Organization who provides the coverage). Same value as ExplanationOfBenefit.insurer    
ExplanationOfBenefit insurance preAuthRef 0..* string Prior authorization reference number            
ExplanationOfBenefit insurance 0..1 BackboneElement Patient insurance information              
ExplanationOfBenefit insurance focal 1..1 boolean Coverage to be used for adjudication New value = false        
ExplanationOfBenefit insurance coverage--> 1..1 Reference(Coverage) Insurance information Ref (3) Contained        
ExplanationOfBenefit insurance coverage--> 1..1 Reference(Coverage) Insurance information “Ref (2)          
Ref (140)” Claim primary payer identifier Coverage.payer--> Organization.identifier Contained (The Plan Organization who provides the coverage). Same value as ExplanationOfBenefit.insurer                
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 36 Line number        
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 1..1 CodeableConcept Revenue or cost center code 86 Revenue center code [1..1] (CD-CHAR(4)) UB-04 “coding.system = url of code system    
coding.code = the code value”                      
ExplanationOfBenefit item revenue Example Revenue Center Codes(Example) 86 Revenue center code [1..1] (CD-CHAR(4)) UB-04          
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 define default value (Lisa to recommend)          
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              
ExplanationOfBenefit item serviced servicedPeriod Period              
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 42 Number of units “1..1]      
NUMERIC (S7.3)”                      
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            
adjudicationamounttype ExplanationOfBenefit item adjudication 1..* BackboneElement Adjudication details          
adjudicationamounttype ExplanationOfBenefit item adjudication category 1..1 CodeableConcept Type of adjudication information New (20)      
adjudicationamounttype ExplanationOfBenefit item adjudication category Adjudication Value Codes(Example) New (20) values: submitted | allowed | deductible |co-insurance | co-pay | non-covered amount | co-ordination of benefits amount | payment amount | patient pay amount        
adjudicationamounttype ExplanationOfBenefit item adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome        
adjudicationamounttype ExplanationOfBenefit item adjudication reason Adjudication Reason Codes(Example)            
adjudicationamounttype ExplanationOfBenefit item adjudication amount 0..1 Money Monetary amount 20 Amounts NUMERIC ( S8.2 (11))  
adjudicationamounttype ExplanationOfBenefit item adjudication value 0..1 decimal Non-monitary value        
inoutnetwork ExplanationOfBenefit item adjudication 1..1 BackboneElement Adjudication details          
inoutnetwork ExplanationOfBenefit item adjudication category 1..1 CodeableConcept Type of adjudication information 142 Line benefit payment status    
inoutnetwork ExplanationOfBenefit item adjudication category Adjudication Value Codes(Example) 142 Line benefit payment status values: in network | out of network | other      
inoutnetwork ExplanationOfBenefit item adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome        
inoutnetwork ExplanationOfBenefit item adjudication reason Adjudication Reason Codes(Example)            
inoutnetwork ExplanationOfBenefit item adjudication amount 0..1 Money Monetary amount        
inoutnetwork ExplanationOfBenefit item adjudication value 0..1 decimal Non-monitary value        
denialreason ExplanationOfBenefit item adjudication 0..* BackboneElement Adjudication details          
denialreason ExplanationOfBenefit item adjudication category 1..1 CodeableConcept Type of adjudication information 92 Claim Payment Denial Code    
denialreason ExplanationOfBenefit item adjudication category Adjudication Value Codes(Example) 92 Claim Payment Denial Code values: denialreason      
denialreason ExplanationOfBenefit item adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome 92 Claim Payment Denial Code [0..1] (CD) “coding.system = url of code system
coding.code = the code value” Claim Adjustment Reason Code (CARC) codes shall be used; optionally allow the Remittance Advice Remark Codes (RARCs)                    
denialreason ExplanationOfBenefit item adjudication reason Adjudication Reason Codes(Example) 92 Claim Payment Denial Code [0..1] (CD)      
denialreason ExplanationOfBenefit item adjudication amount 0..1 Money Monetary amount        
denialreason 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..* seeadjudication 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..* seeadjudication 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..* seeadjudication 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..* seeadjudication 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..* seeadjudication Added items adjudication        
ExplanationOfBenefit adjudication 0..* seeadjudication Header-level adjudication              
ExplanationOfBenefit total 0..* BackboneElement Adjudication totals              
ExplanationOfBenefit total category 1..1 CodeableConcept Type of adjudication information            
ExplanationOfBenefit total category Adjudication Value Codes(Example)                
ExplanationOfBenefit total amount 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 91 Claim payment status code [1..1] (CD) “coding.system = url of code system    
coding.code = the code value”                      
ExplanationOfBenefit payment type Example Payment Type Codes(Example) 91 Claim payment status code [1..1] (CD)          
ExplanationOfBenefit payment adjustment 0..1 Money Payment adjustment for non-claim issues            
ExplanationOfBenefit payment adjustmentReason 0..1 CodeableConcept Explanation for the variance 92 Claim Payment Denial Code [0..1] (CD) “coding.system = url of code system    
coding.code = the code value” Claim Adjustment Reason Code (CARC) codes shall be used; optionally allow the Remittance Advice Remark Codes (RARCs)                    
ExplanationOfBenefit payment adjustmentReason Payment Adjustment Reason Codes(Example) 92 Claim Payment Denial Code [0..1] (CD)          
ExplanationOfBenefit payment date 0..1 date Expected date of payment 107 Claim paid date [1..1] (TS8)      
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(Preferredbut limited toAllLanguages)                
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