CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0-snapshot1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Inpatient Institutional Basis

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional-Basis Version: 2.1.0-snapshot1
Standards status: Trial-use Computable Name: C4BBExplanationOfBenefitInpatientInstitutionalBasis

The basis profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services. The basis profile does not have requirements for financial data.

​This profile is defines the base requirements for an Inpatient Institutional ExplanationOfBenefit. All of the requirements are an exact subset of the original profile from earlier versions with only the financial data element requirements removed in order to address the use case of sharing Non-Financial Claims Data that enables other FHIR Implementation Guides to support communication of ExplanationOfBenefit data without financial data. These profiles are not expected to be implemented directly within the context of the consumer directed data exchange use case defined by this guide, but rather from within the context in which external guides may define (e.g. Provider Access API of PDEX).

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • The determination of inpatient vs. outpatient institutional claims is defined by the Type of Bill. The NUBC manual defines which TOBs are inpatient vs outpatient.
  • A CPT / HCPCS code may not be available on an inpatient institutional claim. The cardinality of the HL7 base EOB Resource for item.productOrService is 1..1 if .item is provided.  Since .item.revenue is required it means that item.productOrService must be populated.  Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason when a CPT / HCPCS code is not available.
  • .diagnosis:  ICD-10 / ICD-9 diagnosis codes are defined as CodeableConcepts
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indicate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
  • .procedure:  ICD-10 / ICD-9 procedure codes are defined as CodeableConcepts
  • .procedure.sequence rule:  procedure.sequence values do not necessarily indicate any order in which the procedure occurred.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of procedure.type to identify primary and secondary procedures
  • .supportingInfo[DRG]:  DRGs require the DRG system; i.e., MS-DRG / AP-DRG / APR-DRG, the DRG version and the code value
  • .adjudication[benefitpaymentstatus]:  in network or out of network payment status for the claim
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... identifier S 1..* Identifier Business Identifier for the resource
... type 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... created S 1..1 dateTime Response creation date
... provider 1..1 Reference(C4BB Organization) Party responsible for the claim
... careTeam C 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingPeriod S 1..1 Period When it occurred
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S 0..* BackboneElement Clinical procedures performed
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... item
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
...... value S 1..1 decimal Non-monitary value
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... payment
.... date S 0..1 date Expected date of payment
... processNote
.... text S 0..1 string Note explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... meta SΣ 1..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization) Party responsible for the claim
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... payee SC 0..1 BackboneElement Recipient of benefits payable
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo S 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S 1..1 Period When it occurred
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S 0..* BackboneElement Clinical procedures performed
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
... item S 1..* BackboneElement Product or service provided
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
...... value S 1..1 decimal Non-monitary value
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... payment S 0..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S 0..1 date Expected date of payment
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... text S 0..1 string Note explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: institutional
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier S 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created SΣ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee SC 0..1 BackboneElement Recipient of benefits payable
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam SC 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Closed by type:$this
..... Slices for timing[x] Content/Rules for all slices
...... timing[x]:timingPeriod S 1..1 Period When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S 1..1 date When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure S 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value S 1..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text S 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ExplanationOfBenefit.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: institutional
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
http://hl7.org/fhir/ValueSet/provider-qualification
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admissionperiod.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admissionperiod.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.supportingInfo:drg.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 11 elements(16 nested mandatory elements)
Must-Support: 56 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.timing[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

Differential View

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... identifier S 1..* Identifier Business Identifier for the resource
... type 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... created S 1..1 dateTime Response creation date
... provider 1..1 Reference(C4BB Organization) Party responsible for the claim
... careTeam C 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Open by type:$this
...... timing[x]:timingPeriod S 1..1 Period When it occurred
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S 0..* BackboneElement Clinical procedures performed
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... item
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
...... value S 1..1 decimal Non-monitary value
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... payment
.... date S 0..1 date Expected date of payment
... processNote
.... text S 0..1 string Note explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... meta SΣ 1..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization) Party responsible for the claim
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... payee SC 0..1 BackboneElement Recipient of benefits payable
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo S 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S 1..1 Period When it occurred
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S 0..* BackboneElement Clinical procedures performed
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
... item S 1..* BackboneElement Product or service provided
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
...... value S 1..1 decimal Non-monitary value
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... payment S 0..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S 0..1 date Expected date of payment
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... text S 0..1 string Note explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: institutional
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier S 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: inpatient
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created SΣ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee SC 0..1 BackboneElement Recipient of benefits payable
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam SC 0..* BackboneElement Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S 1..* BackboneElement Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admissionperiod
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] 1..1 Period When it occurred
Slice: Unordered, Closed by type:$this
..... Slices for timing[x] Content/Rules for all slices
...... timing[x]:timingPeriod S 1..1 Period When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S 1..1 date When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: typeofbill
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Type of Bill Codes Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pointoforigin
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Point Of Origin Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:admtype S 0..1 BackboneElement Admission type
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: admtype
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: discharge-status
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: drg
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code S 1..1 CodeableConcept Type of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
..... Slices for value[x] Content/Rules for all slices
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure S 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S 0..1 dateTime When the procedure was performed
.... procedure[x] S 1..1 CodeableConcept Specific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity S 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1 Money Monetary amount
...... value S 1..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text S 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ExplanationOfBenefit.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredPattern: institutional
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.subTyperequiredPattern: inpatient
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBInstitutionalClaimSubType
from this IG
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInstitutionalCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
http://hl7.org/fhir/ValueSet/provider-qualification
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admissionperiod.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admissionperiod.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCTypeOfBill
from this IG
ExplanationOfBenefit.supportingInfo:typeofbill.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPointOfOriginForAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:pointoforigin.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPriorityTypeOfAdmissionOrVisit
from this IG
ExplanationOfBenefit.supportingInfo:admtype.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPatientDischargeStatus
from this IG
ExplanationOfBenefit.supportingInfo:discharge-status.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSMS3MAPAPRDRG
from this IG
ExplanationOfBenefit.supportingInfo:drg.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimInpatientInstitutionalDiagnosisType
from this IG
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCPresentOnAdmission
from this IG
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProcedureType
from this IG
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSICD910PCSProcedureCodes
from this IG
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AHANUBCRevenueCodes
from this IG
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBEOBInstitutionalProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ExplanationOfBenefit.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ExplanationOfBenefit.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
http://hl7.org/fhir/ValueSet/benefit-network
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-unit
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
http://hl7.org/fhir/ValueSet/benefit-term
from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes
http://hl7.org/fhir/ValueSet/benefit-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists()).exists() and supportingInfo.where(code.coding.where(system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).exists()).not() and (supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit').exists() and code.coding.where(code = '4').exists().not()).exists() and supportingInfo.where(code.coding.where(system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists()).exists() ).not()

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 11 elements(16 nested mandatory elements)
Must-Support: 56 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.timing[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

 

Other representations of profile: CSV, Excel, Schematron