CARIN Blue Button Implementation Guide CI Build

CARIN Blue Button, CARIN Alliance - CI build for vesion 0.1.37-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 Pharmacy 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 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) New                
ExplanationOfBenefit type 1..1 CodeableConcept Category or discipline 16 Claim type values: Pharmacy        
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: Pharmacy 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 Contained        
ExplanationOfBenefit billablePeriod 0..1 Period Relevant time frame for the claim              
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 (5) Claim payer Identifier Organization.identifier Same as insurance.coverage.organization. Party responsible for reimbursing the provider.      
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                  
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 (95, 96, 122) Provider NPIs [1..1] CHAR(10) PractionerRole.practioner --> Practioner.identifier PractionerRole.code = pcp | prescribing  
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 value = 1      
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)              
claimrecvddate ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
claimrecvddate ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 88 value = 1      
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)              
dayssupply ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
dayssupply ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 77 value = 1      
dayssupply ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 77 value = ‘dayssupply’      
dayssupply ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
dayssupply ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information          
dayssupply ExplanationOfBenefit supportingInfo code Exception Codes(Example)              
dayssupply ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
dayssupply ExplanationOfBenefit supportingInfo timing timingDate date            
dayssupply ExplanationOfBenefit supportingInfo timing timingPeriod Period            
dayssupply ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
dayssupply ExplanationOfBenefit supportingInfo value valueBoolean boolean            
dayssupply ExplanationOfBenefit supportingInfo value valueString string            
dayssupply ExplanationOfBenefit supportingInfo value valueQuantity Quantity 77 Days supply [1..1] NUMERIC (S3.0) value=positive integer defined by Regex(0|[1-9][0-9]*), unit=”d”    
dayssupply ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
dayssupply ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
dayssupply ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
dayssupply ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
dawcode ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
dawcode ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 79 value = 1      
dawcode ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 79 value = ‘dawcode’      
dawcode ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
dawcode ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 79 DAW product selection code ”[1..1] CHAR(2)    
Industry standard code”                    
                       
Value set is in ResDAC”                      
dawcode ExplanationOfBenefit supportingInfo code Exception Codes(Example) 79 NCPDP field # 408-D8 (Dispensed As Written (DAW)/Product Selection Code) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200387000&system=sdo          
dawcode ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
dawcode ExplanationOfBenefit supportingInfo timing timingDate date            
dawcode ExplanationOfBenefit supportingInfo timing timingPeriod Period            
dawcode ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
dawcode ExplanationOfBenefit supportingInfo value valueBoolean boolean            
dawcode ExplanationOfBenefit supportingInfo value valueString string            
dawcode ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
dawcode ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
dawcode ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
dawcode ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
dawcode ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
refillnum ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
refillnum ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 137 reference supportinginfo.sequence rule      
refillnum ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 137 value = ‘refillnum’      
refillnum ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
refillnum ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information          
refillnum ExplanationOfBenefit supportingInfo code Exception Codes(Example)              
refillnum ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
refillnum ExplanationOfBenefit supportingInfo timing timingDate date            
refillnum ExplanationOfBenefit supportingInfo timing timingPeriod Period            
refillnum ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
refillnum ExplanationOfBenefit supportingInfo value valueBoolean boolean            
refillnum ExplanationOfBenefit supportingInfo value valueString string            
refillnum ExplanationOfBenefit supportingInfo value valueQuantity Quantity 137 Refill number [1..1] NUMERIC (S3.0) value=positive integer defined by Regex(0|[1-9][0-9]*), unit=”d”    
refillnum ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
refillnum ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
refillnum ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
refillnum ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
rxorigincode ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
rxorigincode ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 143 reference supportinginfo.sequence rule      
rxorigincode ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 143 value = ‘rxorigincode’      
rxorigincode ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
rxorigincode ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 143 Prescription origin code      
rxorigincode ExplanationOfBenefit supportingInfo code Exception Codes(Example) 143 NCPDP field # 419-DJ (Prescription Origin Code) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200387000&system=sdo          
rxorigincode ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
rxorigincode ExplanationOfBenefit supportingInfo timing timingDate date            
rxorigincode ExplanationOfBenefit supportingInfo timing timingPeriod Period            
rxorigincode ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
rxorigincode ExplanationOfBenefit supportingInfo value valueBoolean boolean            
rxorigincode ExplanationOfBenefit supportingInfo value valueString string            
rxorigincode ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
rxorigincode ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
rxorigincode ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
rxorigincode ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
rxorigincode ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
brandgeneric ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
brandgeneric ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 144 reference supportinginfo.sequence rule      
brandgeneric ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 144 value = ‘brandgeneric’      
brandgeneric ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
brandgeneric ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 144 Plan reported brand-generic code ”[1..1] CHAR(1)    
Industry standard code”                      
brandgeneric ExplanationOfBenefit supportingInfo code Exception Codes(Example) NCPDP field # 686 (Brand/Generic Indicator) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200197000&system=sdo            
brandgeneric ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
brandgeneric ExplanationOfBenefit supportingInfo timing timingDate date            
brandgeneric ExplanationOfBenefit supportingInfo timing timingPeriod Period            
brandgeneric ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
brandgeneric ExplanationOfBenefit supportingInfo value valueBoolean boolean            
brandgeneric ExplanationOfBenefit supportingInfo value valueString string            
brandgeneric ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
brandgeneric ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
brandgeneric ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
brandgeneric ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
brandgeneric ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
brandgeneric ExplanationOfBenefit supportingInfo 1..1 BackboneElement Supporting information            
dispensingstatus ExplanationOfBenefit supportingInfo sequence 1..1 positiveInt Information instance identifier 80 reference supportinginfo.sequence rule      
dispensingstatus ExplanationOfBenefit supportingInfo category 1..1 CodeableConcept Classification of the supplied information 80 value = ‘dispensingstatus’      
dispensingstatus ExplanationOfBenefit supportingInfo category Claim Information Category Codes(Example)              
dispensingstatus ExplanationOfBenefit supportingInfo code 0..1 CodeableConcept Type of information 80 ”[1..1] CHAR(1)      
Industry standard code”                      
dispensingstatus ExplanationOfBenefit supportingInfo code Exception Codes(Example) NCPDP field # 343-HD (Dispensing Status) https://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=60594000            
dispensingstatus ExplanationOfBenefit supportingInfo timing 0..1 When it occurred            
dispensingstatus ExplanationOfBenefit supportingInfo timing timingDate date            
dispensingstatus ExplanationOfBenefit supportingInfo timing timingPeriod Period            
dispensingstatus ExplanationOfBenefit supportingInfo value 0..1 Data to be provided            
dispensingstatus ExplanationOfBenefit supportingInfo value valueBoolean boolean            
dispensingstatus ExplanationOfBenefit supportingInfo value valueString string            
dispensingstatus ExplanationOfBenefit supportingInfo value valueQuantity Quantity            
dispensingstatus ExplanationOfBenefit supportingInfo value valueAttachment Attachment            
dispensingstatus ExplanationOfBenefit supportingInfo value valueReference--> Reference(Any)            
dispensingstatus ExplanationOfBenefit supportingInfo reason 0..1 Coding Explanation for the information          
dispensingstatus ExplanationOfBenefit supportingInfo reason Missing Tooth Reason Codes(Example)              
ExplanationOfBenefit diagnosis 0..* BackboneElement Pertinent diagnosis information              
ExplanationOfBenefit diagnosis sequence 1..1 positiveInt Diagnosis instance identifier            
ExplanationOfBenefit diagnosis diagnosis 1..1 CodeableConcept Nature of illness or problem            
ExplanationOfBenefit diagnosis diagnosis ICD-10 Codes(Example)                
ExplanationOfBenefit diagnosis diagnosis Reference(Condition)                
ExplanationOfBenefit diagnosis type 0..* CodeableConcept Timing or nature of the diagnosis            
ExplanationOfBenefit diagnosis type Example Diagnosis Type Codes(Example)                
ExplanationOfBenefit diagnosis onAdmission 0..1 CodeableConcept Present on admission            
ExplanationOfBenefit diagnosis onAdmission Example Diagnosis on Admission Codes(Example)                
ExplanationOfBenefit diagnosis packageCode 0..1 CodeableConcept Package billing code            
ExplanationOfBenefit diagnosis packageCode Example Diagnosis Related Group Codes(Example)                
ExplanationOfBenefit procedure 0..* BackboneElement Clinical procedures performed              
ExplanationOfBenefit procedure sequence 1..1 positiveInt Procedure instance identifier            
ExplanationOfBenefit procedure type 0..* CodeableConcept Category of Procedure            
ExplanationOfBenefit procedure type Example Procedure Type Codes(Example)                
ExplanationOfBenefit procedure date 0..1 dateTime When the procedure was performed            
ExplanationOfBenefit procedure procedure 1..1 Specific clinical procedure              
ExplanationOfBenefit procedure procedure ICD-10 Procedure Codes(Example)                
ExplanationOfBenefit procedure procedure procedureCodeableConcept CodeableConcept              
ExplanationOfBenefit procedure procedure procedureReference--> Reference(Procedure)              
ExplanationOfBenefit procedure udi 0..* Reference(Device) Unique device identifier            
ExplanationOfBenefit precedence 0..1 positiveInt Precedence (primary, secondary, etc.)              
ExplanationOfBenefit insurance 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)          
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 “INT      
                     
ExplanationOfBenefit item careTeamSequence 0..* positiveInt Applicable care team members            
ExplanationOfBenefit item diagnosisSequence 0..* positiveInt Applicable diagnoses            
ExplanationOfBenefit item procedureSequence 0..* positiveInt Applicable procedures            
ExplanationOfBenefit item informationSequence 0..* positiveInt Applicable exception and supporting information            
ExplanationOfBenefit item revenue 0..1 CodeableConcept Revenue or cost center code            
ExplanationOfBenefit item revenue Example Revenue Center Codes(Example)                
ExplanationOfBenefit item category 0..1 CodeableConcept Benefit classification 34 Type of service [1.1] (CD-CHAR(5)) “coding.system = url of code system    
coding.code = the code value”                      
ExplanationOfBenefit item category Benefit Category Codes(Example) 34 [1.1] (CD-CHAR(5))            
ExplanationOfBenefit item productOrService 1..1 CodeableConcept Billing, service, product, or drug code 38, 78 “National drug code        
Compound Code” ”[1..1] CHAR(11)                    
Industry standard code”                      
ExplanationOfBenefit item productOrService USCLS Codes(Example) 38, 78 ”[1..1] CHAR(11)            
Industry standard code” “Value set will be NDC Codes when Compound Code = 0 or 1. When the Compound Code = 2, productOrService = ““compound””                    
                       
When the Compound Code = 2, map the ingredient to ExplanationOfBenefit.detail.subDetail.productOrService” “https://www.hl7.org/fhir/claim-example-pharmacy-compound.json.html                    
                     
ExplanationOfBenefit item modifier 0..* CodeableConcept Product or service billing modifiers            
ExplanationOfBenefit item modifier Modifier type Codes(Example)                
ExplanationOfBenefit item programCode 0..* CodeableConcept Program the product or service is provided under            
ExplanationOfBenefit item programCode Example Program Reason Codes(Example)                
ExplanationOfBenefit item serviced 0..1 Date or dates of service or product delivery              
ExplanationOfBenefit item serviced servicedDate date Date or dates of service or product delivery 90 Service (from) date [1..1] (TS8)      
ExplanationOfBenefit item serviced servicedPeriod Period Date or dates of service or product delivery            
ExplanationOfBenefit item location 0..1 Place of service or where product was supplied              
ExplanationOfBenefit item location Example Service Place Codes(Example)                
ExplanationOfBenefit item location locationCodeableConcept CodeableConcept              
ExplanationOfBenefit item location locationAddress Address              
ExplanationOfBenefit item location locationReference--> Reference(Location)              
ExplanationOfBenefit item quantity 0..1 SimpleQuantity Count of products or services 39 ”[1..1]        
NUMERIC (S7.3)” We are going to look at the option to point to MedicationDispense Resource                    
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 missing Missing data element: compound ingredient ”[0..*] CHAR(11)  
                     
ExplanationOfBenefit item detail subDetail productOrService USCLS Codes(Example) missing Value set may be local codes when the explanationOfbenefit.item.productOrService = “compound” https://www.hl7.org/fhir/claim-example-pharmacy-compound.json.html      
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) What will this value set be?        
ExplanationOfBenefit payment adjustment 0..1 Money Payment adjustment for non-claim issues            
ExplanationOfBenefit payment adjustmentReason 0..1 CodeableConcept Explanation for the variance            
ExplanationOfBenefit payment adjustmentReason Payment Adjustment Reason Codes(Example)                
ExplanationOfBenefit payment date 0..1 date Expected date of payment 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