CARIN Consumer Directed Payer Data Exchange
0.1.3 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.1.3). 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: 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 official URL for this profile is:

http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 5 elements (7 nested mandatory elements)
Must-Support: 25 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.supportingInfo.timing[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:$this (Closed)
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of value:category (Closed)
  • The element ExplanationOfBenefit.total is sliced based on the value of value:category

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... meta S0..1MetaDefines the date the Resource was created or updated, whichever is later.
... identifier S1..*IdentifierIdentifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. This unique identifier assigned by the payer becomes the payer's EOB identifier.
... status S1..1codeactive | cancelled | draft | entered-in-error
.... 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
.... coding S1..1CodingCode defined by a terminology system
... patient 1..1Reference(C4BB Patient)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided.
... billablePeriod
.... start S0..1dateTimeThe first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’)
.... end S0..1dateTimeThe last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’)
... created S1..1dateTimeResponse creation date
... insurer 1..1Reference(C4BB Organization)Name of the payer responsible for the claim
... provider 1..1Reference(C4BB Organization)The name of the Billing Provider
... related 0..*BackboneElementIf the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.
... payee
.... type 1..1CodeableConceptIdentifies the type of recipient of the adjudication amount; i.e., provider or subscriber or another recipient
.... party 1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... careTeam I0..*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
.... provider 1..1Reference(C4BB Organization | C4BB Practitioner)The name of the operating surgeon.
.... role 1..1CodeableConceptThe functional role of a provider on a claim.
Binding: C4BB Claim Institutional Care Team Role (required)
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101)
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code 1..1CodeableConceptIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission.
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:claimrecvddate 0..1BackboneElementThe date the claim was received by the payer (88)
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: claimrecvddate
..... timing[x] 1..1(Slice Definition)When it occurred
Slice: Unordered, Open by type:$this
..... timingDate 0..1dateThe date the claim was received by the payer
.... supportingInfo:typeofbill 0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17)
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
..... code 0..1CodeableConceptType of information
Binding: AHA NUBC Type of Bill (required)
.... supportingInfo:pointoforigin 0..1BackboneElementIdentifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13)
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
..... code 0..1CodeableConceptIdentifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15).
Binding: AHA NUBC Point of Origin for Admission or Visit. (required)
.... supportingInfo:admtype 0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
..... code 0..1CodeableConceptPriority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled.
Binding: AHA NUBC Priority Type Of Admission Or Visit (required)
.... supportingInfo:discharge-status 0..1BackboneElementDischarge Status
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
..... code 0..1CodeableConceptPatient’s status as of the discharge date for an institutional stay. Information located on UB04 (Form Locator 17).
Binding: AHA NUBC Patient Discharge Status (required)
.... supportingInfo:drg 0..1BackboneElementClaim diagnosis related group (DRG)
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
..... code 0..1CodeableConceptDRG codes assigned
Binding: CMS-DRG (required)
.... supportingInfo:admissionperiod 0..1BackboneElementAdmission Period
..... 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/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionperiod
..... timing[x] 1..1(Slice Definition)When it occurred
Slice: Unordered, Open by type:$this
..... timingPeriod 1..1PeriodWhen it occurred
... diagnosis S1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field.
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: ICD-10-CM Diagnosis Codes (required)
.... type S1..1CodeableConceptDescription of this field
Binding: C4BB Claim Inpatient Institutional Diagnosis Type (required)
.... onAdmission S0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities.
Binding: AHA NUBC Present On Admission (required)
... procedure 0..*BackboneElementDate of Procedure - Secondary
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
... insurance 1..*BackboneElementName of the payer responsible for the claim
... item
.... sequence S1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing.
.... revenue S0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed
Binding: AHA NUBC Revenue Codes (required)
.... productOrService S1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII).
Binding: AMA CPT CMS HCPCS Procedure Codes (required)
.... modifier S0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.
Binding: AMA CPT CMS HCPCS Modifiers (required)
.... quantity S0..1SimpleQuantityThe 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.
.... adjudication 0..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by pattern:$this
..... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount S0..1MoneyMonetary amount
..... adjudication:denialreason 0..1BackboneElementDenial Reason
...... 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/ClaimAdjudicationCategory
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC) (required)
..... adjudication:allowedunits 0..1BackboneElementAllowed number of units
...... 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/ClaimAdjudicationCategory
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... adjudication 0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
.... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:denialreason 0..1BackboneElementDenial Reason
..... 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/ClaimAdjudicationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
..... reason 1..1CodeableConceptReason codes used to interpret the Non-Covered Amount that are provided to the Provider
Binding: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC) (required)
... total 1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
.... total:adjudicationamounttype S0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount 1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.)
.... total:inoutnetwork S1..1BackboneElementBenefit Payment Status
..... category 1..1CodeableConceptIndicates the in network or out of network payment status of the claim.
Binding: C4BB Payer Benefit Payment Status (required)
... payment
.... type S0..1CodeableConceptIndicates whether the claim was paid or denied.
.... date S0..1dateThe date the claim was paid.
... processNote
.... text S0..1stringLine payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta SΣI0..1MetaDefines the date the Resource was created or updated, whichever is later.
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*IdentifierIdentifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. This unique identifier assigned by the payer becomes the payer's EOB identifier.
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type SΣI1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value ΣI0..1stringThe value that is unique
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type SΣI1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.).
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique 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
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣI1..1CodingCode defined by a terminology system
.... text ΣI0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use ΣI1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣI1..1Reference(C4BB Patient)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided.
... billablePeriod SΣI0..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣI0..1dateTimeThe first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’)
.... end SΣI0..1dateTimeThe last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’)
... created SΣI1..1dateTimeResponse creation date
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣI1..1Reference(C4BB Organization)Name of the payer responsible for the claim
... provider SΣI1..1Reference(C4BB Organization)The name of the Billing Provider
... priority I0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related SI0..*BackboneElementIf the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship SI1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription I0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI1..1CodeableConceptIdentifies the type of recipient of the adjudication amount; i.e., provider or subscriber or another recipient
Binding: Claim Payee Type Codes (required)
.... party SI1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... referral I0..1Reference(ServiceRequest)Treatment Referral
... facility I0..1Reference(Location)Servicing Facility
... claim I0..1Reference(Claim)Claim reference
... claimResponse I0..1Reference(ClaimResponse)Claim response reference
... outcome ΣI1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition I0..1stringDisposition Message
... preAuthRef I0..*stringPreauthorization reference
... preAuthRefPeriod I0..*PeriodPreauthorization in-effect period
... careTeam SI0..*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 I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntOrder of care team
.... provider SI1..1Reference(C4BB Organization | C4BB Practitioner)The name of the operating surgeon.
.... responsible SI0..1booleanIndicator of the lead practitioner
.... role SI1..1CodeableConceptThe functional role of a provider on a claim.
Binding: C4BB Claim Institutional Care Team Role (required)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo SI0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:billingnetworkcontractingstatus SI0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptIndicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission.
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:claimrecvddate SI0..1BackboneElementThe date the claim was received by the payer (88)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: claimrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1(Slice Definition)When it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingDate SI0..1dateThe date the claim was received by the payer
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:typeofbill SI0..1BackboneElementUB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: typeofbill
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: AHA NUBC Type of Bill (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:pointoforigin SI0..1BackboneElementIdentifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admsrc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptIdentifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15).
Binding: AHA NUBC Point of Origin for Admission or Visit. (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:admtype SI0..1BackboneElementClaim Priority (Type) of Admission or Visit
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admtype
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptPriority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled.
Binding: AHA NUBC Priority Type Of Admission Or Visit (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:discharge-status SI0..1BackboneElementDischarge Status
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: discharge-status
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptPatient’s status as of the discharge date for an institutional stay. Information located on UB04 (Form Locator 17).
Binding: AHA NUBC Patient Discharge Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:drg SI0..1BackboneElementClaim diagnosis related group (DRG)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: drg
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptDRG codes assigned
Binding: CMS-DRG (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:admissionperiod SI0..1BackboneElementAdmission Period
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique 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/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionperiod
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1(Slice Definition)When it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod SI1..1PeriodWhen it occurred
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis SI1..*BackboneElementThis is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field.
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] SI1..1CodeableConceptNature of illness or problem
Binding: ICD-10-CM Diagnosis Codes (required)
.... type SI1..1CodeableConceptDescription of this field
Binding: C4BB Claim Inpatient Institutional Diagnosis Type (required)
.... onAdmission SI0..1CodeableConceptUsed to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities.
Binding: AHA NUBC Present On Admission (required)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure SI0..*BackboneElementDate of Procedure - Secondary
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type SI0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date SI0..1dateTimeWhen the procedure was performed
.... procedure[x] SI1..1CodeableConceptSpecific clinical procedure
Binding: ICD-10-PCS (required)
.... udi I0..*Reference(Device)Unique device identifier
... precedence I0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SΣI1..*BackboneElementName of the payer responsible for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣI1..1booleanCoverage to be used for adjudication
.... coverage SΣI1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef I0..*stringPrior authorization reference number
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I0..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing.
.... careTeamSequence I0..*positiveIntApplicable care team members
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue SI0..1CodeableConceptCode used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed
Binding: AHA NUBC Revenue Codes (required)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptMedical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII).
Binding: AMA CPT CMS HCPCS Procedure Codes (required)
.... modifier SI0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.
Binding: AMA CPT CMS HCPCS Modifiers (required)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConcept