CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1  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 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

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional Version: 2.1.0
Standards status: Trial-use 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. The profile has requirements for financial data.

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 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
  • ExplanationOfBenefit.adjudication elements may contain slices for both billing network status (billingnetworkstatus) and benefit payment status (benefitpaymentstatus) which each contain a reason code bound to very similar ValueSets that indicate network status. The billing network status indicates the general relationship (often a contract status) the billing provider has with the payer. The benefit payment status indicates how the service or product is covered (in or out of network) in context to its provisioning. These two values may be different.
    An example of this is where an in network provider that has billed for a service that is not within the scope of the contract of service with the payer.
  • 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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefitInpatientInstitutionalBasis Explanation of Benefit resource
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
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-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... meta SΣ 1..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... lastUpdated SΣ 1..1 instant When the resource version last changed
ele-1: All FHIR elements must have a @value or children
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... 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.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
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.


ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (required)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
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.


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


ele-1: All FHIR elements must have a @value or children
... careTeam SC 0..* BackboneElement Care Team members
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Order of care team
ele-1: All FHIR elements must have a @value or children
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
ele-1: All FHIR elements must have a @value or children
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
ele-1: All FHIR elements must have a @value or children
... Slices for supportingInfo S 1..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:admissionperiod S 1..1 BackboneElement Admission Period
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
...... timing[x]:timingPeriod S 1..1 Period When it occurred
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:typeofbill S 0..1 BackboneElement Type of bill
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:pointoforigin S 0..1 BackboneElement Point of origin for admission
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:admtype S 0..1 BackboneElement Admission type
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:discharge-status S 0..1 BackboneElement Discharge status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:drg S 0..1 BackboneElement Diagnosis Related Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Diagnosis instance identifier
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... onAdmission S 0..1 CodeableConcept Present on admission
Binding: CMS Present On Admission Indicator Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
... procedure S 0..* BackboneElement Clinical procedures performed
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Procedure instance identifier
ele-1: All FHIR elements must have a @value or children
.... type S 1..1 CodeableConcept Category of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... date S 0..1 dateTime When the procedure was performed
ele-1: All FHIR elements must have a @value or children
.... 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)
ele-1: All FHIR elements must have a @value or children
... insurance SΣC 1..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
... item SC 1..* BackboneElement Product or service provided
ele-1: All FHIR elements must have a @value or children
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence S 1..1 positiveInt Item instance identifier
ele-1: All FHIR elements must have a @value or children
.... revenue S 1..1 CodeableConcept Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... quantity S 0..1 SimpleQuantity Count of products or services
ele-1: All FHIR elements must have a @value or children
.... noteNumber S 0..* positiveInt Applicable note numbers
ele-1: All FHIR elements must have a @value or children
.... Slices for adjudication S 0..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
..... 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)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
..... adjudication:adjudicationamounttype S 0..* BackboneElement Line level adjudication type and amount
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
ele-1: All FHIR elements must have a @value or children
...... amount S 1..1 Money Monetary amount
ele-1: All FHIR elements must have a @value or children
... Slices for adjudication S 1..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider network status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
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)
ele-1: All FHIR elements must have a @value or children
.... adjudication:adjudicationamounttype S 0..* BackboneElement Claim level adjudication type and amount
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
ele-1: All FHIR elements must have a @value or children
..... amount 1..1 Money Monetary amount
ele-1: All FHIR elements must have a @value or children
... Slices for total SΣ 1..* BackboneElement Adjudication totals
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... amount Σ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
.... total:adjudicationamounttype SΣ 1..* BackboneElement Total adjudication type and amount
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
ele-1: All FHIR elements must have a @value or children
..... amount SΣ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
... payment S 0..1 BackboneElement Payment Details
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... date S 0..1 date Expected date of payment
ele-1: All FHIR elements must have a @value or children
... processNote S 0..* BackboneElement Note concerning adjudication
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... text S 0..1 string Note explanatory text
ele-1: All FHIR elements must have a @value or children

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.onAdmissionrequiredCMSPresentOnAdmissionIndicator
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPresentOnAdmissionIndicator
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.categoryextensiblePattern: adjustmentreason
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.item.adjudication:allowedunits.categoryextensiblePattern: allowedunits
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryextensiblePattern: billingnetworkstatus
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.categoryextensiblePattern: benefitpaymentstatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.categoryextensiblePattern: adjustmentreason
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTotalCategoryDiscriminator
from this IG
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-institutional-inpatient-meta-profile-versionwarningExplanationOfBenefitInstitutional 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|2.1'))
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())

 

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