CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.0.0 - STU 2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 2.0.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Inpatient Institutional

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional Version: 2.0.0
Active as of 2022-11-28 Computable Name: C4BBExplanationOfBenefitInpatientInstitutional

The 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.

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
  • CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts and amount types are to be provided in EOB.item.  If a Payer does not have line item amounts, provide the claim amounts and amount types in the EOB header data elements.  Total amounts and amount types of the claim are to be provided in EOB.total.  The in network or out of network payment status of the claim are to be provided in EOB.supportingInfo.
  • 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.amount (populate only if item.adjudication is not available):  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .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:

  • This Resource Profile is not used by any profiles in this Implementation Guide

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 C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
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.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... identifier S1..*IdentifierBusiness Identifier for the resource
... type 1..1CodeableConceptCategory or discipline
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
.... end S0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created S1..1dateTimeResponse creation date
... provider 1..1Reference(C4BB Organization)Party responsible for the claim
... careTeam C0..*BackboneElementCare 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..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo 1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionperiod
..... timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Open by type:$this
..... timingPeriod S1..1PeriodWhen it occurred
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:typeofbill S0..1BackboneElementType of bill
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
..... code S1..1CodeableConceptType of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
..... code S1..1CodeableConceptType of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge status
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... item C1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S0..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S0..1BackboneElementThe 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..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
...... value S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount 1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

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 role.where(coding.where(code in ('rendering' )).exists()).exists().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' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().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.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
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.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... meta SΣ1..1MetaMetadata about the resource
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
..... value SΣ1..1stringUnique Claim Identifier
Example General: 123456
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..1PeriodRelevant time frame for the claim
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*BackboneElementCare 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo S1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionperiod
..... Slices for timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S1..1PeriodWhen it occurred
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:typeofbill S0..1BackboneElementType of bill
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
..... code S1..1CodeableConceptType of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: pointoforigin
..... code S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
..... code S1..1CodeableConceptType of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... insurance SΣC1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣ1..1booleanCoverage to be used for adjudication
.... coverage SΣ1..1Reference(C4BB Coverage)Insurance information
... item SC1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S0..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:allowedunits S0..1BackboneElementThe 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
...... value S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... Slices for total SΣ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SΣ1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S0..1dateExpected date of payment
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

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 role.where(coding.where(code in ('rendering' )).exists()).exists().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' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().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.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
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.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... id Σ0..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier S1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription 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
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ1..1stringUnique Claim Identifier
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SΣ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

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

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SC0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SC0..*BackboneElementCare 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..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)