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