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

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

Resource Profile: C4BB ExplanationOfBenefit Oral

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral Version: 2.0.0
Active as of 2022-11-28 Computable Name: C4BBExplanationOfBenefitOral

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.

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total If there is a mix of lines paid in network and out of network on a claim, the value of C4BB Payer Benefit Payment Status is ‘Other’
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indicate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
  • .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
  • .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
  • .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
  • .item.productOrService: CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on an oral claim
  • .item.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the line
  • The line item primary body site (tooth or oral cavity) SHALL be specified in the .item.bodySite. Additional body sites (tooth or oral cavity) SHALL be specified in supportingInfo[additionalbodysite] repetitions with supportingInfo[additionalbodysite].sequence matching the line items .item.informationSequence
  • All Oral line item subsites (.item.subSite repetitions) apply to all the line item's associated tooth surfaces (item.bodySite and .supportingInfo[additionalbodysite] associated with the line item by referencing supportingInfo[additionalbodysite].sequence through .item.informationSequence)
  • .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

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

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-oral-meta-profile-version: Oral EOB: meta.profile with canonical and major.minor. version required.
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]
... type 1..1CodeableConceptCategory or discipline
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: oral
... provider 1..1Reference(C4BB Practitioner)Party responsible for the claim
... careTeam C0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Open by type:$this
..... valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:orthodontics S0..1BackboneElementOrthodontics treatment indicator
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: orthodontics
..... code 0..1CodeableConceptType of information
..... timingDate 0..1dateOrthodontics appliance application date (200)
..... value[x] S1..1QuantityData to be provided
Slice: Unordered, Open by type:$this
..... valueQuantity 1..1QuantityTotal number of months for orthodontia
.... supportingInfo:prosthesis S0..1BackboneElementProsthesis
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: prosthesis
..... timingDate 0..1dateDate of prior prosthesis replacement (203)
..... value[x] S1..1booleanData to be provided
Slice: Unordered, Open by type:$this
..... valueBoolean 1..1booleanProsthesis replacement indicator (202
.... supportingInfo:additionalbodysite S0..*BackboneElementAdditional tooth number or oral cavity code
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalbodysite
..... code S1..1CodeableConceptType of information
Binding: Oral Body Site Value Set (required)
.... supportingInfo:missingtoothnumber S0..*BackboneElementMissing tooth number
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: missingtoothnumber
..... code S1..1CodeableConceptType of information
Binding: American Dental Association Universal Numbering Value Set (required)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
... diagnosis S0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] S1..1date, PeriodDate or dates of service or product delivery
.... location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... bodySite S0..1CodeableConceptFirst tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..*CodeableConceptTooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S0..1BackboneElementThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for adjudication S2..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:renderingnetworkstatus S1..1BackboneElementRendering provider network status
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..*BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
..... amount 1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.locationCodeableConceptrequiredCMSPlaceofServiceCodes
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes (a valid code from US Surface Codes System)
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-oral-meta-profile-versionerrorExplanationOfBenefitOral EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.0.'))
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.code = 'additionalbodysite').sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.where(coding.system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem' and category.coding.code = 'additionalbodysite').sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt 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.code = 'additionalbodysite').sequence).exists()).where(bodySite.count() != count()).empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-oral-meta-profile-version: Oral EOB: meta.profile with canonical and major.minor. version required.
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]
... meta SΣ1..1MetaMetadata about the resource
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: oral
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..1PeriodRelevant time frame for the claim
.... start SΣC1..1dateTimeStarting time with inclusive boundary
... created Σ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Practitioner)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:orthodontics S0..1BackboneElementOrthodontics treatment indicator
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: orthodontics
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for value[x] S1..1QuantityData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueQuantity 1..1QuantityTotal number of months for orthodontia
.... supportingInfo:prosthesis S0..1BackboneElementProsthesis
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: prosthesis
..... Slices for value[x] S1..1booleanData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueBoolean 1..1booleanProsthesis replacement indicator (202
.... supportingInfo:additionalbodysite S0..*BackboneElementAdditional tooth number or oral cavity code
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalbodysite
..... code S1..1CodeableConceptType of information
Binding: Oral Body Site Value Set (required)
.... supportingInfo:missingtoothnumber S0..*BackboneElementMissing tooth number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: missingtoothnumber
..... code S1..1CodeableConceptType of information
Binding: American Dental Association Universal Numbering Value Set (required)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
... diagnosis S0..*BackboneElementPertinent diagnosis information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... insurance SΣC1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣ1..1booleanCoverage to be used for adjudication
.... coverage SΣ1..1Reference(C4BB Coverage)Insurance information
... item S1..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: ADA Code on Dental Procedures and Nomenclature Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] S1..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... Slices for location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... location[x]:locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... bodySite S0..1CodeableConceptFirst tooth number or oral cavity code
Binding: Oral Body Site Value Set (required)
.... subSite 0..*CodeableConceptTooth surface for all teeth on line
Binding: US Surface Codes Set Value Set (required)
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S0..1BackboneElementThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for adjudication S2..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


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


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


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
... Slices for total SΣ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: oral
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
ExplanationOfBenefit.supportingInfo:orthodontics.categoryextensiblePattern: orthodontics
ExplanationOfBenefit.supportingInfo:orthodontics.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:prosthesis.categoryextensiblePattern: prosthesis
ExplanationOfBenefit.supportingInfo:additionalbodysite.categoryextensiblePattern: additionalbodysite
ExplanationOfBenefit.supportingInfo:additionalbodysite.coderequiredOralBodySite
ExplanationOfBenefit.supportingInfo:missingtoothnumber.categoryextensiblePattern: missingtoothnumber
ExplanationOfBenefit.supportingInfo:missingtoothnumber.coderequiredADAUniversalNumberingSystem
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
ExplanationOfBenefit.item.productOrServicerequiredADADentalProcedureCode
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.location[x]:locationCodeableConceptrequiredCMSPlaceofServiceCodes
ExplanationOfBenefit.item.bodySiterequiredOralBodySite
ExplanationOfBenefit.item.subSiterequiredC4BBSurfaceCodes (a valid code from US Surface Codes System)
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.categoryexampleAdjudicationValueCodes
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-oral-meta-profile-versionerrorExplanationOfBenefitOral EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.0.'))
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner) )
Oral-EOB-supportinginfo-additionalbodysite-requires-line-itemerrorExplanationOfBenefitsupportingInfo repetitions with additional body site must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.coding.code = 'additionalbodysite').sequence.subsetOf(%context.item.informationSequence)
Oral-EOB-surface-subsite-requires-tooth-numbererrorExplanationOfBenefitIf item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite]
: item.where(subSite.exists() and (bodySite.where(coding.system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.system='http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem' and category.coding.code = 'additionalbodysite').sequence).isDistinct())).count() = 0
Oral-line-item-with-linked-additionalbody-site-requires-bodysiteerrorExplanationOfBenefitAt 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.code = 'additionalbodysite').sequence).exists()).where(bodySite.count() != count()).empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-oral-meta-profile-version: Oral EOB: meta.profile with canonical and major.minor. version required.
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]
... id Σ0..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


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

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

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: oral
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

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

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

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SC0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1