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 Pharmacy mapping

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Slice L0 L1 L2 L3 L4 Flag Cardinalityy 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 RX service reference number
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) New
ExplanationOfBenefit type Σ 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 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 Contained
ExplanationOfBenefit billablePeriod Σ 0..1 Period Relevant time frame for the claim
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 (5) Claim payer Identifier Organization.identifier Same as insurance.coverage.organization. Party responsible for reimbursing the provider.
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 
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 (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 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)
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 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
https://www.resdac.org/sites/resdac.umn.edu/files/CMS%20Type%20of%20Service%20Table.txt
ExplanationOfBenefit item category Benefit Category Codes (Example) 34 Type of service [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.item.detail.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 |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))
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 38 National drug code [1..1] CHAR(11)
Industry standard code
ExplanationOfBenefit item detail productOrService USCLS Codes (Example) 38 [1..1] CHAR(11)
Industry standard code
When the Compound Code = 2, map the NDC as the ingredient https://www.hl7.org/fhir/claim-example-pharmacy-compound.json.html
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
adjudicationamounttype ExplanationOfBenefit adjudication category Adjudication Value Codes (Example) 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
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
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) 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 (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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