Consumer-Directed Payer Data Exchange
- Release 0.1.0

Consumer-Directed Payer Data Exchange, published by CARIN Alliance. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

EOB Inpatient Facility mapping

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Slice L0 L1 L2 L3 L4 Flag Cardinality DataType /
Value Set
Description MapID CARIN CPCDS Data Element Name Cardinality /
DataType
Value Set Comments Working Note
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 35 Claim unique identifier
ExplanationOfBenefit status ?!Σ 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 Σ 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 Σ 1..1 code claim | preauthorization | predetermination New value = claim
ExplanationOfBenefit use Use (Required)
ExplanationOfBenefit patient--> Σ 1..1 Reference(Patient) The recipient of the products and services Ref (1) Member id [1.1] (CHAR) Contained
ExplanationOfBenefit patient--> Σ 1..1 Reference(Patient) The recipient of the products and services Ref (109) Patient account number [1.1] (CHAR) Contained
ExplanationOfBenefit patient--> Σ 1..1 Reference(Patient) The recipient of the products and services Ref (110) Medical record number [1.1] (CHAR) Contained
ExplanationOfBenefit billablePeriod Σ 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 Σ 1..1 dateTime Response creation date new [1..1] (TS8)  [1]
ExplanationOfBenefit enterer--> 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
ExplanationOfBenefit insurer--> Σ 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--> Σ 1..1 Reference(PractionerRole) Party responsible for the claim Ref (89) [0..1] (CD-CHAR(5)) Organization.address.zipcode
ExplanationOfBenefit provider--> Σ 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 111, 112 Claim adjusted from identifier
Claim adjusted to identifier
ExplanationOfBenefit related claim--> 0..1 Reference(Claim) Reference to the related claim
ExplanationOfBenefit related relationship 0..1 CodeableConcept How the reference claim is related New(111, 112)
ExplanationOfBenefit related relationship Example Related Claim Relationship Codes (Example) New(111, 112) values set TBD
prior | replaced by
ExplanationOfBenefit related reference 0..1 Identifier File or case reference 111, 112
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 Σ 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)
typeofservice ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information
typeofservice ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 34 reference supportinginfo.sequence rule
typeofservice ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 34 value = 'typeofservice'
typeofservice ExplanationOfBenefit supportingInfo category Claim Information Category Codes (Example) 34
typeofservice 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
https://www.resdac.org/sites/resdac.umn.edu/files/CMS%20Type%20of%20Service%20Table.txt
typeofservice ExplanationOfBenefit supportingInfo code Exception Codes (Example) 34 Type of service [1.1] (CD-CHAR(5))
typeofservice ExplanationOfBenefit supportingInfo timing 0..1 When it occurred
typeofservice ExplanationOfBenefit supportingInfo timing timingDate date
typeofservice ExplanationOfBenefit supportingInfo timing timingPeriod Period
typeofservice ExplanationOfBenefit supportingInfo value 0..1 Data to be provided
typeofservice ExplanationOfBenefit supportingInfo value valueBoolean boolean
typeofservice ExplanationOfBenefit supportingInfo value valueString string
typeofservice ExplanationOfBenefit supportingInfo value valueQuantity Quantity
typeofservice ExplanationOfBenefit supportingInfo value valueAttachment Attachment
typeofservice ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)
typeofservice ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information
typeofservice 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-ICD-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 code [1..1] (CD-ICD-9) or (CD-ICD-10) ICD-9 or
ICD-10
(Required)
ExplanationOfBenefit diagnosis diagnosis Reference(Condition)
ExplanationOfBenefit diagnosis type 1..1 CodeableConcept Timing or nature of the diagnosis New (6, 7, 8, 21, 22, 23, 30, 31) [1..1] (CD)
ExplanationOfBenefit diagnosis type Example Diagnosis Type Codes (Example) New (6, 7, 8, 21, 22, 23, 30, 31) [1..1] (CD) Diagnosis Type
principal | secondary | patient reason for visit | external cause of injury
Create a value set with these four concepts from SNOMED CT system
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 Σ 1..1 BackboneElement Patient insurance information
ExplanationOfBenefit insurance focal Σ 1..1 boolean Coverage to be used for adjudication New value = true
ExplanationOfBenefit insurance coverage--> Σ 1..1 Reference(Coverage) Insurance information Ref (3) Contained
ExplanationOfBenefit insurance coverage--> Σ 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 Σ 0..1 BackboneElement Patient insurance information
ExplanationOfBenefit insurance focal Σ 1..1 boolean Coverage to be used for adjudication New value = false
ExplanationOfBenefit insurance coverage--> Σ 1..1 Reference(Coverage) Insurance information Ref (3) Contained
ExplanationOfBenefit insurance coverage--> Σ 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 |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability
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)) May be populated
adjudicationamounttype 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..* 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
adjudicationamounttype ExplanationOfBenefit adjudication 1..* BackboneElement Header-level adjudication
adjudicationamounttype ExplanationOfBenefit adjudication category 1..1 CodeableConcept Type of adjudication information New (20)
adjudicationamounttype ExplanationOfBenefit adjudication category Adjudication Value Codes (Example) New (20) values: submitted | allowed | deductible |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability
adjudicationamounttype ExplanationOfBenefit adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome
adjudicationamounttype ExplanationOfBenefit adjudication reason Adjudication Reason Codes (Example)
adjudicationamounttype ExplanationOfBenefit adjudication amount 0..1 Money Monetary amount 20 Amounts NUMERIC ( S8.2 (11))
adjudicationamounttype ExplanationOfBenefit adjudication value 0..1 decimal Non-monitary value
inoutnetwork ExplanationOfBenefit adjudication 1..1 BackboneElement Header-level adjudication
inoutnetwork ExplanationOfBenefit adjudication category 1..1 CodeableConcept Type of adjudication information 142 Line benefit payment status
inoutnetwork ExplanationOfBenefit adjudication category Adjudication Value Codes (Example) 142 Line benefit payment status values: in network | out of network | other
inoutnetwork ExplanationOfBenefit adjudication reason 0..1 CodeableConcept Explanation of adjudication outcome
inoutnetwork ExplanationOfBenefit adjudication reason Adjudication Reason Codes (Example)
inoutnetwork ExplanationOfBenefit adjudication amount 0..1 Money Monetary amount
inoutnetwork ExplanationOfBenefit adjudication value 0..1 decimal Non-monitary value
denialreason ExplanationOfBenefit adjudication 0..* BackboneElement Header-level adjudication
denialreason ExplanationOfBenefit adjudication category 1..1 CodeableConcept Type of adjudication information 92 Claim Payment Denial Code
denialreason ExplanationOfBenefit adjudication category Adjudication Value Codes (Example) 92 Claim Payment Denial Code values: denialreason
denialreason ExplanationOfBenefit 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 adjudication reason Adjudication Reason Codes (Example) 92 Claim Payment Denial Code [0..1] (CD)
denialreason ExplanationOfBenefit adjudication amount 0..1 Money Monetary amount
denialreason ExplanationOfBenefit adjudication value 0..1 decimal Non-monitary value
ExplanationOfBenefit total Σ 1..* BackboneElement Adjudication totals 148 [1..12]
ExplanationOfBenefit total category Σ 1..1 CodeableConcept Type of adjudication information New (148) [1..1] (CD)
ExplanationOfBenefit total category Adjudication Value Codes (Example) New (148) values: submitted | allowed | deductible |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability
ExplanationOfBenefit total amount Σ 1..1 Money Financial total for the category 148 Total Amount [1..1]NUMERIC ( S8.2 (11))
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 (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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