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
Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral-Basis | Version: 2.1.0 | |||
Standards status: Trial-use | Computable Name: C4BBExplanationOfBenefitOralBasis |
This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. The basis profile does not have requirements for financial data.
This profile is defines the base requirements for an Oral ExplanationOfBenefit. All of the requirements are an exact subset of the original profile from earlier versions with only the financial data element requirements removed in order to address the use case of sharing Non-Financial Claims Data that enables other FHIR Implementation Guides to support communication of ExplanationOfBenefit data without financial data. These profiles are not expected to be implemented directly within the context of the consumer directed data exchange use case defined by this guide, but rather from within the context in which external guides may define (e.g. Provider Access API of PDEX).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints![]() |
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C | 0..* | C4BBExplanationOfBenefit | 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 Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
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SΣ | 1..1 | Meta | Metadata about the resource ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | instant | When the resource version last changed ele-1: All FHIR elements must have a @value or children |
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Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to ele-1: All FHIR elements must have a @value or children |
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?!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 |
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?! | 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 |
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1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children | |
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Content/Rules for all slices | |||
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?!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 |
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S | 1..1 | Identifier | Unique Claim Identifier ele-1: All FHIR elements must have a @value or children |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |
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SΣ | 1..1 | string | Unique Claim Identifier ele-1: All FHIR elements must have a @value or children Example General: 123456 |
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?!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 |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
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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 |
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SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | Period | Relevant time frame for the claim ele-1: All FHIR elements must have a @value or children |
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SΣC | 1..1 | dateTime | Starting time with inclusive boundary ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | dateTime | Response creation date ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | Reference(C4BB Practitioner | C4BB Organization) | Party responsible for the claim ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Prior or corollary claims ele-1: All FHIR elements must have a @value or children |
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?!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 |
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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 |
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S | 1..1 | Identifier | File or case reference ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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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 |
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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 |
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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 |
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SC | 0..* | BackboneElement | Care Team members ele-1: All FHIR elements must have a @value or children EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
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?!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 |
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1..1 | positiveInt | Order of care team ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization ele-1: All FHIR elements must have a @value or children |
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S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required) ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy ![]() ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children |
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Content/Rules for all slices | |||
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 | |
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S | 0..1 | BackboneElement | Claim received date ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
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S | 1..1 | date | When it occurred ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | BackboneElement | Service facility ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
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1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | Reference(C4BB Organization) | Data to be provided ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | BackboneElement | Orthodontics treatment indicator ele-1: All FHIR elements must have a @value or children |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
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0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. ele-1: All FHIR elements must have a @value or children | |
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0..1 | When it occurred Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children | ||
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date | |||
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Period | |||
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0..1 | date | Orthodontics appliance application date (200) ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | Quantity | Total number of months for orthodontia ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | BackboneElement | Prosthesis ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
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0..1 | When it occurred Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children | ||
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date | |||
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Period | |||
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0..1 | date | Date of prior prosthesis replacement (203) ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | boolean | Prosthesis replacement indicator (202 ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Additional tooth number or oral cavity code ele-1: All FHIR elements must have a @value or children |
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?!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 |
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S | 1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
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S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Missing tooth number ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
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S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | BackboneElement | Medical record number ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
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1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | string | Data to be provided ele-1: All FHIR elements must have a @value or children |
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S | 0..1 | BackboneElement | Patient account number ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Information instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
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1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children | |
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S | 1..1 | string | Data to be provided ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Pertinent diagnosis information ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | positiveInt | Diagnosis instance identifier ele-1: All FHIR elements must have a @value or children | |
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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 |
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S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required) ele-1: All FHIR elements must have a @value or children |
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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 |
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?!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 |
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SΣ | 1..1 | boolean | Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information ele-1: All FHIR elements must have a @value or children |
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S | 1..* | BackboneElement | Product or service provided ele-1: All FHIR elements must have a @value or children |
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?!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 |
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S | 1..1 | positiveInt | Item instance identifier ele-1: All FHIR elements must have a @value or children |
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S | 0..* | positiveInt | Applicable exception and supporting information ele-1: All FHIR elements must have a @value or children |
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S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required) ele-1: All FHIR elements must have a @value or children |
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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 |
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S | 1..1 | Date or dates of service or product delivery ele-1: All FHIR elements must have a @value or children | |
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date | |||
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Period | |||
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S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) Value Set (required) ele-1: All FHIR elements must have a @value or children |
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0..1 | SimpleQuantity | Count of products or services ele-1: All FHIR elements must have a @value or children | |
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S | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) ele-1: All FHIR elements must have a @value or children |
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0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set Value Set (required) ele-1: All FHIR elements must have a @value or children | |
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S | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children |
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S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children |
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Content/Rules for all slices | |||
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?!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 |
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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 |
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S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) ele-1: All FHIR elements must have a @value or children |
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?!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 |
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
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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 |
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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 |
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?!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 |
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
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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 |
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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 |
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?!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 |
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
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S | 2..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category ele-1: All FHIR elements must have a @value or children |
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Content/Rules for all slices | |||
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?!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 |
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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 |
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S | 0..1 | BackboneElement | Billing provider network status ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
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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 |
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S | 1..1 | BackboneElement | Rendering provider network status ele-1: All FHIR elements must have a @value or children |
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?!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 |
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1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
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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 |
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S | 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 |
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?!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 |
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1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
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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 |
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S | 0..1 | BackboneElement | Payment Details ele-1: All FHIR elements must have a @value or children |
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?!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 |
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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 |
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S | 0..* | BackboneElement | Note concerning adjudication ele-1: All FHIR elements must have a @value or children |
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?!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 |
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Path | Conformance | ValueSet / Code | URI |
ExplanationOfBenefit.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.identifier:uniqueclaimid.type | extensible | Pattern: uchttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.type | required | Pattern: oralhttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ExplanationOfBenefit.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes from this IG | |
ExplanationOfBenefit.payee.type | required | C4BBPayeeTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType from this IG | |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | |
ExplanationOfBenefit.careTeam.role | required | C4BBClaimProfessionalAndNonClinicianCareTeamRolehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole from this IG | |
ExplanationOfBenefit.careTeam.qualification | required | HealthcareProviderTaxonomy ![]() http://nucc.org/provider-taxonomy )http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:clmrecvddate.category | extensible | Pattern: clmrecvddatehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:servicefacility.category | extensible | Pattern: servicefacilityhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:orthodontics.category | extensible | Pattern: orthodonticshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:orthodontics.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard | |
ExplanationOfBenefit.supportingInfo:prosthesis.category | extensible | Pattern: prosthesishttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:additionalbodysite.category | extensible | Pattern: additionalbodysitehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:additionalbodysite.code | required | OralBodySitehttp://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite from this IG | |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.category | extensible | Pattern: missingtoothnumberhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.code | required | ADAUniversalNumberingSystemhttp://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem from this IG | |
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category | extensible | Pattern: medicalrecordnumberhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.supportingInfo:patientaccountnumber.category | extensible | Pattern: patientaccountnumberhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType from this IG | |
ExplanationOfBenefit.diagnosis.diagnosis[x] | required | CDCICD910CMDiagnosisCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes from this IG | |
ExplanationOfBenefit.diagnosis.type | required | C4BBClaimProfessionalAndNonClinicianDiagnosisTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType from this IG | |
ExplanationOfBenefit.item.productOrService | required | ADADentalProcedureCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode from this IG | |
ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSModifiershttp://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers from this IG | |
ExplanationOfBenefit.item.location[x] | required | CMSPlaceofServiceCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes from this IG | |
ExplanationOfBenefit.item.bodySite | required | OralBodySitehttp://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite from this IG | |
ExplanationOfBenefit.item.subSite | required | C4BBSurfaceCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.category | example | Pattern: adjustmentreasonhttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG | |
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunitshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.category | example | Pattern: billingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | example | Pattern: renderingnetworkstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | example | Pattern: benefitpaymentstatushttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG | |
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-prof-careTeam-practitioner | error | ExplanationOfBenefit.careTeam | Professional EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) ) | |
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item | error | ExplanationOfBenefit | supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence : supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence) | |
Oral-EOB-surface-subsite-requires-tooth-number | error | ExplanationOfBenefit | If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] : item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0 | |
Oral-line-item-with-linked-additionalbody-site-requires-bodysite | error | ExplanationOfBenefit | At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence : item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty() |
This structure is derived from C4BBExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints![]() |
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C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
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1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
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1..1 | Reference(C4BB Practitioner | C4BB Organization) | Party responsible for the claim | |
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C | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
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1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required) | |
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S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy ![]() |
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0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category | |
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S | 0..1 | BackboneElement | Claim received date |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
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S | 1..1 | date | When it occurred |
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S | 0..1 | BackboneElement | Service facility |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
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1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Open by type:$this | |
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S | 1..1 | Reference(C4BB Organization) | Data to be provided |
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S | 0..1 | BackboneElement | Orthodontics treatment indicator |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
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0..1 | CodeableConcept | Type of information | |
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0..1 | date, Period | When it occurred Slice: Unordered, Open by type:$this | |
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0..1 | date | Orthodontics appliance application date (200) | |
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S | 1..1 | Quantity | Total number of months for orthodontia |
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S | 0..1 | BackboneElement | Prosthesis |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
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0..1 | date, Period | When it occurred Slice: Unordered, Open by type:$this | |
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0..1 | date | Date of prior prosthesis replacement (203) | |
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S | 1..1 | boolean | Prosthesis replacement indicator (202 |
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S | 0..* | BackboneElement | Additional tooth number or oral cavity code |
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S | 1..1 | positiveInt | Information instance identifier |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
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S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) |
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S | 0..* | BackboneElement | Missing tooth number |
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S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
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S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) |
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S | 0..1 | BackboneElement | Medical record number |
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1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
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1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
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S | 1..1 | string | Data to be provided |
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S | 0..1 | BackboneElement | Patient account number |
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1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
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1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
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S | 1..1 | string | Data to be provided |
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S | 0..* | BackboneElement | Pertinent diagnosis information |
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1..1 | positiveInt | Diagnosis instance identifier | |
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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) |
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S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required) |
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S | 0..* | positiveInt | Applicable exception and supporting information |
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S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required) |
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S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required) |
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S | 1..1 | date, Period | Date or dates of service or product delivery |
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S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) Value Set (required) |
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0..1 | SimpleQuantity | Count of products or services | |
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S | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) |
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0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set Value Set (required) | |
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S | 1..* | BackboneElement | Adjudication details Slice: Unordered, Open by value:category |
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Content/Rules for all slices | |||
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1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) | |
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S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: adjustmentreason | |
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S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required) |
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S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
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S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required) |
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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) |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
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S | 2..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by value:category |
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Content/Rules for all slices | |||
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S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible) |
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S | 0..1 | BackboneElement | Billing provider network status |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkstatus | |
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S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required) |
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S | 1..1 | BackboneElement | Rendering provider network status |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus | |
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S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required) |
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S | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
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1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus | |
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S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required) |
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Path | Conformance | ValueSet | URI |
ExplanationOfBenefit.careTeam.role | required | C4BBClaimProfessionalAndNonClinicianCareTeamRolehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole from this IG | |
ExplanationOfBenefit.careTeam.qualification | required | HealthcareProviderTaxonomy ![]() http://nucc.org/provider-taxonomy )http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066 | |
ExplanationOfBenefit.supportingInfo:additionalbodysite.code | required | OralBodySitehttp://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite from this IG | |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.code | required | ADAUniversalNumberingSystemhttp://hl7.org/fhir/us/carin-bb/ValueSet/ADAUniversalNumberingSystem from this IG | |
ExplanationOfBenefit.diagnosis.diagnosis[x] | required | CDCICD910CMDiagnosisCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes from this IG | |
ExplanationOfBenefit.diagnosis.type | required | C4BBClaimProfessionalAndNonClinicianDiagnosisTypehttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType from this IG | |
ExplanationOfBenefit.item.productOrService | required | ADADentalProcedureCodehttp://hl7.org/fhir/us/carin-bb/ValueSet/ADADentalProcedureCode from this IG | |
ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSModifiershttp://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers from this IG | |
ExplanationOfBenefit.item.location[x] | required | CMSPlaceofServiceCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes from this IG | |
ExplanationOfBenefit.item.bodySite | required | OralBodySitehttp://hl7.org/fhir/us/carin-bb/ValueSet/OralBodySite from this IG | |
ExplanationOfBenefit.item.subSite | required | C4BBSurfaceCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSurfaceCodes from this IG | |
ExplanationOfBenefit.item.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodeshttp://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG | |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG | |
ExplanationOfBenefit.adjudication.category | extensible | C4BBAdjudicationCategoryDiscriminatorhttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator from this IG | |
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | required | C4BBPayerProviderNetworkStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus from this IG | |
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | required | C4BBPayerBenefitPaymentStatushttp://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus from this IG |
Id | Grade | Path(s) | Details | Requirements |
EOB-prof-careTeam-practitioner | error | ExplanationOfBenefit.careTeam | Professional EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner) ) | |
Oral-EOB-supportinginfo-additionalbodysite-requires-line-item | error | ExplanationOfBenefit | supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence : supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence.subsetOf(%context.item.informationSequence) | |
Oral-EOB-surface-subsite-requires-tooth-number | error | ExplanationOfBenefit | If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] : item.where(subSite.exists() and (bodySite.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.where(system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists() and category.coding.where(code = 'additionalbodysite').exists()).sequence).isDistinct())).count() = 0 | |
Oral-line-item-with-linked-additionalbody-site-requires-bodysite | error | ExplanationOfBenefit | At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence : item.where(informationSequence.intersect(%context.supportingInfo.where(category.coding.where(code = 'additionalbodysite').exists()).sequence).exists()).where(bodySite.count() != count()).empty() |
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
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C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-supportinginfo-additionalbodysite-requires-line-item: supportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence Oral-line-item-with-linked-additionalbody-site-requires-bodysite: At least one item.bodySite needs to be present if an item.informationSequence references supportingInfo[additionalbodysite].sequence Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] | ||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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SΣ | 1..1 | Meta | Metadata about the resource | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 0..1 | id | Version specific identifier | ||||
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SΣ | 1..1 | instant | When the resource version last changed | ||||
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Σ | 0..1 | uri | Identifies where the resource comes from | ||||
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Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
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Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
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Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
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0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by value:type | |||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 0..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. | ||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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S | 1..1 | Identifier | Unique Claim Identifier | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 1..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: uc | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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SΣ | 1..1 | string | Unique Claim Identifier Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
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SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim | ||||
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SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services | ||||
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SΣ | 1..1 | Period | Relevant time frame for the claim | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
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ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
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Σ | 1..1 | dateTime | Response creation date | ||||
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0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
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SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement | ||||
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SΣ | 1..1 | Reference(C4BB Practitioner | C4BB Organization) | Party responsible for the claim | ||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
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0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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S | 0..* | BackboneElement | Prior or corollary claims | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required) | ||||
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S | 1..1 | Identifier | File or case reference | ||||
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0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
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0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
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SC | 0..1 | BackboneElement | Recipient of benefits payable EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type Value Set (required) | ||||
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S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference | ||||
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0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
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0..1 | Reference(Location) | Servicing Facility | |||||
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0..1 | Reference(Claim) | Claim reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | string | Preauthorization reference | |||||
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0..* | Period | Preauthorization in-effect period | |||||
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SC | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | ||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
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S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required) | ||||
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S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy ![]() | ||||
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S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Information instance identifier | |||||
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1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) | |||||
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0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
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0..1 | When it occurred | ||||||
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date | |||||||
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Period | |||||||
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0..1 | Data to be provided | ||||||
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boolean | |||||||
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string | |||||||
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Quantity | |||||||
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Attachment | |||||||
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Reference(Resource) | |||||||
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0..1 |