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: C4BBExplanationOfBenefitOutpatientInstitutional - Detailed Descriptions

Active as of 2022-11-28

Definitions for the C4BB-ExplanationOfBenefit-Outpatient-Institutional resource profile.

1. ExplanationOfBenefit
InvariantsDefined on this element
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. (: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not())
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both (: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient 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-Outpatient-Institutional|2.0.')))
2. ExplanationOfBenefit.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Must Supporttrue
3. ExplanationOfBenefit.type
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
    <code value="institutional"/>
  </coding>
</valueCodeableConcept>
4. ExplanationOfBenefit.subType
Control10..1
BindingThe codes SHALL be taken from C4BB Institutional Claim SubType Value SetFor example codes, see ExampleClaimSubTypeCodes
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
    <code value="outpatient"/>
  </coding>
</valueCodeableConcept>
5. ExplanationOfBenefit.created
Must Supporttrue
6. ExplanationOfBenefit.provider
TypeReference(C4BBOrganization|C4BBPractitioner))
7. ExplanationOfBenefit.careTeam
InvariantsDefined on this element
EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set (: where(role.where(coding.code in ('rendering')).exists().not() or qualification.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066')).exists())
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization (: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) ))
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner (: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) ))
8. ExplanationOfBenefit.careTeam.role
Control10..1
BindingThe codes SHALL be taken from C4BB Claim Institutional Care Team Role Value SetFor example codes, see ClaimCareTeamRoleCodes
9. ExplanationOfBenefit.careTeam.qualification
BindingThe codes SHALL be taken from Healthcare Provider TaxonomyFor example codes, see ExampleProviderQualificationCodes
10. ExplanationOfBenefit.supportingInfo
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
11. ExplanationOfBenefit.supportingInfo:clmrecvddate
SliceNameclmrecvddate
Control0..1
Must Supporttrue
Comments

The date the claim was received by the payer (88)

12. ExplanationOfBenefit.supportingInfo:clmrecvddate.category
Control0..?
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="clmrecvddate"/>
  </coding>
</valueCodeableConcept>
13. ExplanationOfBenefit.supportingInfo:clmrecvddate.timing[x]
Control1..?
Typedate
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
14. ExplanationOfBenefit.supportingInfo:typeofbill
SliceNametypeofbill
Control0..1
Must Supporttrue
Comments

UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17)

15. ExplanationOfBenefit.supportingInfo:typeofbill.category
Control0..?
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="typeofbill"/>
  </coding>
</valueCodeableConcept>
16. ExplanationOfBenefit.supportingInfo:typeofbill.code
Control1..?
BindingThe codes SHALL be taken from NUBC Type of Bill Codes Value Set
Must Supporttrue
17. ExplanationOfBenefit.supportingInfo:pointoforigin
SliceNamepointoforigin
Control0..1
Must Supporttrue
Comments

Identifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13)

18. ExplanationOfBenefit.supportingInfo:pointoforigin.category
Control0..?
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="pointoforigin"/>
  </coding>
</valueCodeableConcept>
19. ExplanationOfBenefit.supportingInfo:pointoforigin.code
Control1..?
BindingThe codes SHALL be taken from NUBC Point Of Origin Value Set
Must Supporttrue
20. ExplanationOfBenefit.supportingInfo:admtype
SliceNameadmtype
Control0..1
Must Supporttrue
Comments

Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. (14)

21. ExplanationOfBenefit.supportingInfo:admtype.category
Control0..?
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="admtype"/>
  </coding>
</valueCodeableConcept>
22. ExplanationOfBenefit.supportingInfo:admtype.code
Control1..?
BindingThe codes SHALL be taken from NUBC Priority (Type) of Admission or Visit Value Set
Must Supporttrue
23. ExplanationOfBenefit.supportingInfo:discharge-status
SliceNamedischarge-status
Control0..1
Must Supporttrue
Comments

Patient’s status as of the discharge date for a facility stay. Information located on UB04. (Form Locator 17). (117)

24. ExplanationOfBenefit.supportingInfo:discharge-status.category
Control0..?
Must Supporttrue
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="discharge-status"/>
  </coding>
</valueCodeableConcept>
25. ExplanationOfBenefit.supportingInfo:discharge-status.code
Control1..?
BindingThe codes SHALL be taken from NUBC Patient Discharge Status Codes Value Set
Must Supporttrue
26. ExplanationOfBenefit.supportingInfo:medicalrecordnumber
SliceNamemedicalrecordnumber
Control0..1
Must Supporttrue
Comments

Provider submitted medical record number that can be included on the claim. (109)

27. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="medicalrecordnumber"/>
  </coding>
</valueCodeableConcept>
28. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]
Control1..?
[x] NoteSee Choice of Data Types for further information about how to use [x]
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
29. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.valueString
Control1..1
Typestring
Must Supporttrue
30. ExplanationOfBenefit.supportingInfo:patientaccountnumber
SliceNamepatientaccountnumber
Control0..1
Must Supporttrue
Comments

Provider assigned patient account number that can be included on the claim. (109)

31. ExplanationOfBenefit.supportingInfo:patientaccountnumber.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="patientaccountnumber"/>
  </coding>
</valueCodeableConcept>
32. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]
Control1..?
[x] NoteSee Choice of Data Types for further information about how to use [x]
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
33. ExplanationOfBenefit.supportingInfo:patientaccountnumber.valueString
Control1..1
Typestring
Must Supporttrue
34. ExplanationOfBenefit.diagnosis
Control10..*
Comments

Diagnosis codes describe an individual's disease or medical condition. (6, 7, 8, 21, 22, 23, 30)

35. ExplanationOfBenefit.diagnosis.sequence
Comments

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 are presented in list order to their expected importance: primary, secondary, etc.

36. ExplanationOfBenefit.diagnosis.diagnosis[x]
BindingThe codes SHALL be taken from Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value SetFor example codes, see ICD-10Codes
TypeChoice of: , Reference(Condition))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
37. ExplanationOfBenefit.diagnosis.type
Control10..1*
BindingThe codes SHALL be taken from C4BB Claim Outpatient Institutional Diagnosis Type Value SetFor example codes, see ExampleDiagnosisTypeCodes
Must Supporttrue
Comments

Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit. (21, 22, 23)

For example: admitting, primary, secondary, discharge.

38. ExplanationOfBenefit.item
InvariantsDefined on this element
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice (: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()))
39. ExplanationOfBenefit.item.revenue
BindingThe codes SHALL be taken from NUBC Revenue Codes Value SetFor example codes, see ExampleRevenueCenterCodes
Must Supporttrue
Comments

Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86)

40. ExplanationOfBenefit.item.productOrService
BindingThe codes SHALL be taken from Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value SetFor example codes, see USCLSCodes
Must Supporttrue
Comments

Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40)

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

41. ExplanationOfBenefit.item.modifier
BindingThe codes SHALL be taken from Procedure Modifier Codes - AMA CPT - CMS HCPCS Value SetFor example codes, see ModifierTypeCodes
Must Supporttrue
Comments

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41)

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

42. ExplanationOfBenefit.item.serviced[x]
Control10..1
TypeChoice of: , Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.serviced[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
43. ExplanationOfBenefit.item.servicedDate
Control1..1
Must Supporttrue
44. ExplanationOfBenefit.item.quantity
Must Supporttrue
Comments

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. (42)

45. ExplanationOfBenefit.item.adjudication
Must Supporttrue
SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
46. ExplanationOfBenefit.item.adjudication.category
BindingThe codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set; other codes may be used where these codes are not suitableFor example codes, see AdjudicationValueCodes
47. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
SliceNameadjudicationamounttype
Control0..*
Must Supporttrue
Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

48. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
Control0..?
BindingThe codes SHALL be taken from C4BB Adjudication Value Set
49. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
Control1..?
Must Supporttrue
50. ExplanationOfBenefit.item.adjudication:adjustmentreason
SliceNameadjustmentreason
Control0..*
Must Supporttrue
Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

51. ExplanationOfBenefit.item.adjudication:adjustmentreason.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="adjustmentreason"/>
  </coding>
</valueCodeableConcept>
52. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason
Control1..?
BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set
Must Supporttrue
53. ExplanationOfBenefit.item.adjudication:allowedunits
SliceNameallowedunits
Control0..1
Must Supporttrue
Comments

The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)

54. ExplanationOfBenefit.item.adjudication:allowedunits.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="allowedunits"/>
  </coding>
</valueCodeableConcept>
55. ExplanationOfBenefit.item.adjudication:allowedunits.value
Control1..?
Must Supporttrue
56. ExplanationOfBenefit.adjudication
Control10..*
TypeBackboneElement
Must Supporttrue
SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
57. ExplanationOfBenefit.adjudication.category
Control0..?
BindingThe codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set; other codes may be used where these codes are not suitable
Must Supporttrue
58. ExplanationOfBenefit.adjudication:billingnetworkstatus
SliceNamebillingnetworkstatus
Control0..1
Must Supporttrue
Comments

Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101)

59. ExplanationOfBenefit.adjudication:billingnetworkstatus.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="billingnetworkstatus"/>
  </coding>
</valueCodeableConcept>
60. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason
Control1..?
BindingThe codes SHALL be taken from C4BB Payer Provider Network Status Value Set
Must Supporttrue
61. ExplanationOfBenefit.adjudication:benefitpaymentstatus
SliceNamebenefitpaymentstatus
Control1..1
Must Supporttrue
Comments

Indicates the in network or out of network payment status of the claim. (142)

62. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="benefitpaymentstatus"/>
  </coding>
</valueCodeableConcept>
63. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason
Control1..?
BindingThe codes SHALL be taken from C4BB Payer Benefit Payment Status Value Set
Must Supporttrue
64. ExplanationOfBenefit.adjudication:adjudicationamounttype
SliceNameadjudicationamounttype
Control0..*
Must Supporttrue
Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

65. ExplanationOfBenefit.adjudication:adjudicationamounttype.category
Control0..?
BindingThe codes SHALL be taken from C4BB Adjudication Value Set
66. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
Control1..?
Must Supporttrue
67. ExplanationOfBenefit.adjudication:adjustmentreason
SliceNameadjustmentreason
Control0..*
Must Supporttrue
Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

68. ExplanationOfBenefit.adjudication:adjustmentreason.category
Control0..?
Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="adjustmentreason"/>
  </coding>
</valueCodeableConcept>
69. ExplanationOfBenefit.adjudication:adjustmentreason.reason
Control1..?
BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set
Must Supporttrue
Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

70. ExplanationOfBenefit.total
SlicingThis element introduces a set of slices on ExplanationOfBenefit.total. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
71. ExplanationOfBenefit.total.category
BindingThe codes SHALL be taken from C4BB Total Category Discriminator Value Set; other codes may be used where these codes are not suitableFor example codes, see AdjudicationValueCodes
Must Supporttrue
72. ExplanationOfBenefit.total.amount
Comments

Total amount for each category (i.e., submitted, allowed, etc.) (148)

73. ExplanationOfBenefit.total:adjudicationamounttype
SliceNameadjudicationamounttype
Control1..*
Must Supporttrue
Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

74. ExplanationOfBenefit.total:adjudicationamounttype.category
Control0..?
BindingThe codes SHALL be taken from C4BB Adjudication Value Set
75. ExplanationOfBenefit.total:adjudicationamounttype.amount
Control0..?
Must Supporttrue
76. ExplanationOfBenefit.payment
Control0..?
77. ExplanationOfBenefit.payment.date
Must Supporttrue
78. ExplanationOfBenefit.processNote
Control0..?
79. ExplanationOfBenefit.processNote.text
Must Supporttrue
1. ExplanationOfBenefit
Definition

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

Control0..*
Alternate NamesEOB
InvariantsDefined on this element
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. (: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not())
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both (: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient 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-Outpatient-Institutional|2.0.')))
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
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 (: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. ExplanationOfBenefit.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control10..1
TypeMeta
Must Supporttrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. ExplanationOfBenefit.meta.lastUpdated
Definition

When the resource last changed - e.g. when the version changed.

Control10..1
Typeinstant
Must Supporttrue
Comments

Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. ExplanationOfBenefit.meta.profile
Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Control10..*
Typecanonical(StructureDefinition))
Comments

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. CPCDS data element (190)

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. ExplanationOfBenefit.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. ExplanationOfBenefit.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
7. ExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..*
TypeIdentifier
Must Supporttrue
Requirements

Allows EOBs to be distinguished and referenced.

Comments

Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ type
8. ExplanationOfBenefit.identifier:uniqueclaimid
SliceNameuniqueclaimid
Definition

A unique identifier assigned to this explanation of benefit.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..1*
TypeIdentifier
Must Supporttrue
Requirements

Allows EOBs to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. ExplanationOfBenefit.identifier:uniqueclaimid.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. ExplanationOfBenefit.identifier:uniqueclaimid.type
Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Control10..1
BindingThe codes SHALL be taken from Identifier Type Codes; other codes may be used where these codes are not suitable

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

TypeCodeableConcept
Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
    <code value="uc"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. ExplanationOfBenefit.identifier:uniqueclaimid.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Control10..1
Typestring
Must Supporttrue
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Example
General:123456
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. ExplanationOfBenefit.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from ExplanationOfBenefitStatus

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue
Must Supporttrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. ExplanationOfBenefit.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Control1..1
BindingThe codes SHALL be taken from ClaimTypeCodesThe codes SHALL be taken from ClaimTypeCodes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Comments

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
    <code value="institutional"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. ExplanationOfBenefit.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Control10..1
BindingThe codes SHALL be taken from C4BB Institutional Claim SubType Value SetFor example codes, see ExampleClaimSubTypeCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
    <code value="outpatient"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. ExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Control1..1
BindingThe codes SHALL be taken from Use

Complete, proposed, exploratory, other.

Typecode
Must Supporttrue
Requirements

This element is required to understand the nature of the request for adjudication.

Comments

Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations

Pattern Valueclaim
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. ExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

Control1..1
TypeReference(C4BBPatient|Patient))
Must Supporttrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Comments

Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. ExplanationOfBenefit.billablePeriod
Definition

The period for which charges are being submitted.

Control10..1
TypePeriod
Must Supporttrue
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. ExplanationOfBenefit.billablePeriod.start
Definition

The start of the period. The boundary is inclusive.

Control10..1 This element is affected by the following invariants: per-1
TypedateTime
Must Supporttrue
Comments

The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)

If the low element is missing, the meaning is that the low boundary is not known.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. ExplanationOfBenefit.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Must Supporttrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Comments

Date the claim was adjudicated (179)

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. ExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Control1..1
TypeReference(C4BBOrganization|Organization))
Must Supporttrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Comments

Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. ExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

Control1..1
TypeReference(C4BBOrganization|Practitioner|PractitionerRole|Organization))
Must Supporttrue
Comments

The identifier assigned to the Billing Provider. (94)

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. ExplanationOfBenefit.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Comments

If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)

For example, for the original treatment and follow-up exams.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. ExplanationOfBenefit.related.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
24. ExplanationOfBenefit.related.relationship
Definition

A code to convey how the claims are related.

Control10..1
BindingThe codes SHALL be taken from C4BB Related Claim Relationship Codes Value SetFor example codes, see ExampleRelatedClaimRelationshipCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. ExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Control10..1
TypeIdentifier
Must Supporttrue
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Comments

For example, Property/Casualty insurer claim number or Workers Compensation case number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. ExplanationOfBenefit.payee
Definition

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

InvariantsDefined on this element
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required (: type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists())
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. ExplanationOfBenefit.payee.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. ExplanationOfBenefit.payee.type
Definition

Type of Party to be reimbursed: Subscriber, provider, other.

Control10..1
BindingThe codes SHALL be taken from C4BB Payee Type Value SetFor example codes, see Claim Payee Type Codes
TypeCodeableConcept
Must Supporttrue
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Comments

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. ExplanationOfBenefit.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Control0..1
TypeReference(C4BBOrganization|C4BBPatient|C4BBPractitioner|C4BBRelatedPerson|Practitioner|PractitionerRole|Organization|Patient|RelatedPerson))
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Comments

Recipient reference (121)

Not required if the payee is 'subscriber' or 'provider'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. ExplanationOfBenefit.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes

The result of the claim processing.

Typecode
Must Supporttrue
Requirements

To advise the requestor of an overall processing outcome.

Comments

Expected value is complete

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. ExplanationOfBenefit.careTeam
Definition

The members of the team who provided the products and services.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Common to identify the responsible and supporting practitioners.

InvariantsDefined on this element
EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set (: where(role.where(coding.code in ('rendering')).exists().not() or qualification.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066')).exists())
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization (: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) ))
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner (: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) ))
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. ExplanationOfBenefit.careTeam.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
33. ExplanationOfBenefit.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Comments

careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. ExplanationOfBenefit.careTeam.provider
Definition

Member of the team who provided the product or service.

Control1..1
TypeReference(C4BBOrganization|C4BBPractitioner|Practitioner|PractitionerRole|Organization))
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Often a regulatory requirement to specify the responsible provider.

Comments

The identifier assigned to the care team. (varies depending on the profile)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. ExplanationOfBenefit.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Control10..1
BindingThe codes SHALL be taken from C4BB Claim Institutional Care Team Role Value SetFor example codes, see ClaimCareTeamRoleCodes
TypeCodeableConcept
Must Supporttrue
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

The functional role of a provider on a claim. (165)

Role might not be required when there is only a single provider listed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. ExplanationOfBenefit.careTeam.qualification
Definition

The qualification of the practitioner which is applicable for this service.

Control0..1
BindingThe codes SHALL be taken from Healthcare Provider TaxonomyFor example codes, see ExampleProviderQualificationCodes
TypeCodeableConcept
Requirements

Need to specify which qualification a provider is delivering the product or service under.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. ExplanationOfBenefit.supportingInfo
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Defines data elements not available in the base EOB resource

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
38. ExplanationOfBenefit.supportingInfo.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
39. ExplanationOfBenefit.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. ExplanationOfBenefit.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. ExplanationOfBenefit.supportingInfo:clmrecvddate
SliceNameclmrecvddate
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

The date the claim was received by the payer (88)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.supportingInfo:clmrecvddate.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
43. ExplanationOfBenefit.supportingInfo:clmrecvddate.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. ExplanationOfBenefit.supportingInfo:clmrecvddate.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="clmrecvddate"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. ExplanationOfBenefit.supportingInfo:clmrecvddate.timing[x]
Definition

The date when or period to which this information refers.

Control10..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.supportingInfo:typeofbill
SliceNametypeofbill
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. ExplanationOfBenefit.supportingInfo:typeofbill.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
48. ExplanationOfBenefit.supportingInfo:typeofbill.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. ExplanationOfBenefit.supportingInfo:typeofbill.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="typeofbill"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. ExplanationOfBenefit.supportingInfo:typeofbill.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control10..1
BindingThe codes SHALL be taken from NUBC Type of Bill Codes Value SetFor example codes, see ExceptionCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
51. ExplanationOfBenefit.supportingInfo:pointoforigin
SliceNamepointoforigin
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Identifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
52. ExplanationOfBenefit.supportingInfo:pointoforigin.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
53. ExplanationOfBenefit.supportingInfo:pointoforigin.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. ExplanationOfBenefit.supportingInfo:pointoforigin.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="pointoforigin"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. ExplanationOfBenefit.supportingInfo:pointoforigin.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control10..1
BindingThe codes SHALL be taken from NUBC Point Of Origin Value SetFor example codes, see ExceptionCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
56. ExplanationOfBenefit.supportingInfo:admtype
SliceNameadmtype
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. (14)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
57. ExplanationOfBenefit.supportingInfo:admtype.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
58. ExplanationOfBenefit.supportingInfo:admtype.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
59. ExplanationOfBenefit.supportingInfo:admtype.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="admtype"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
60. ExplanationOfBenefit.supportingInfo:admtype.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control10..1
BindingThe codes SHALL be taken from NUBC Priority (Type) of Admission or Visit Value SetFor example codes, see ExceptionCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
61. ExplanationOfBenefit.supportingInfo:discharge-status
SliceNamedischarge-status
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Patient’s status as of the discharge date for a facility stay. Information located on UB04. (Form Locator 17). (117)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. ExplanationOfBenefit.supportingInfo:discharge-status.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
63. ExplanationOfBenefit.supportingInfo:discharge-status.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
64. ExplanationOfBenefit.supportingInfo:discharge-status.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="discharge-status"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
65. ExplanationOfBenefit.supportingInfo:discharge-status.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control10..1
BindingThe codes SHALL be taken from NUBC Patient Discharge Status Codes Value SetFor example codes, see ExceptionCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
66. ExplanationOfBenefit.supportingInfo:medicalrecordnumber
SliceNamemedicalrecordnumber
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Provider submitted medical record number that can be included on the claim. (109)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
67. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
68. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
69. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="medicalrecordnumber"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
70. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control10..1
TypeChoice of: string, boolean, Reference(Resource)), Quantity, Attachment
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
71. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]:valueString
SliceNamevalueString
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control10..1
TypeChoice of: string, boolean, Reference(Resource)), Quantity, Attachment
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
72. ExplanationOfBenefit.supportingInfo:patientaccountnumber
SliceNamepatientaccountnumber
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Provider assigned patient account number that can be included on the claim. (109)

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
73. ExplanationOfBenefit.supportingInfo:patientaccountnumber.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
74. ExplanationOfBenefit.supportingInfo:patientaccountnumber.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
75. ExplanationOfBenefit.supportingInfo:patientaccountnumber.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitableFor example codes, see ClaimInformationCategoryCodes
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="patientaccountnumber"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
76. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control10..1
TypeChoice of: string, boolean, Reference(Resource)), Quantity, Attachment
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
77. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]:valueString
SliceNamevalueString
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control10..1
TypeChoice of: string, boolean, Reference(Resource)), Quantity, Attachment
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
78. ExplanationOfBenefit.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Control10..*
TypeBackboneElement
Requirements

Required for the adjudication by provided context for the services and product listed.

Comments

Diagnosis codes describe an individual's disease or medical condition. (6, 7, 8, 21, 22, 23, 30)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
79. ExplanationOfBenefit.diagnosis.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
80. ExplanationOfBenefit.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Comments

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 are presented in list order to their expected importance: primary, secondary, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
81. ExplanationOfBenefit.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Control1..1
BindingThe codes SHALL be taken from Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value SetFor example codes, see ICD-10Codes
TypeChoice of: CodeableConcept, Reference(Condition))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

Provides health context for the evaluation of the products and/or services.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
82. ExplanationOfBenefit.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Control10..1*
BindingThe codes SHALL be taken from C4BB Claim Outpatient Institutional Diagnosis Type Value SetFor example codes, see ExampleDiagnosisTypeCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit. (21, 22, 23)

For example: admitting, primary, secondary, discharge.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
83. ExplanationOfBenefit.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Control1..*
TypeBackboneElement
Must Supporttrue
Requirements

At least one insurer is required for a claim to be a claim.

Comments

Identity of the payers responsible for the claim. (2, 141). All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

InvariantsDefined on this element
EOB-insurance-focal: EOB.insurance: at most one with focal = true (: insurance.select (focal = true).count() < 2)
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
84. ExplanationOfBenefit.insurance.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
85. ExplanationOfBenefit.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Control1..1
Typeboolean
Must Supporttrue
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
86. ExplanationOfBenefit.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Control1..1
TypeReference(C4BBCoverage|Coverage))
Must Supporttrue
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Comments

Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier]

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
87. ExplanationOfBenefit.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Control10..*
TypeBackboneElement
Must Supporttrue
Requirements

The items to be processed for adjudication.

InvariantsDefined on this element
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice (: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()))
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
88. ExplanationOfBenefit.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
89. ExplanationOfBenefit.item.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Must Supporttrue
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Comments

Line identification number that represents the number assigned in a source system for identification and processing. (36)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
90. ExplanationOfBenefit.item.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
BindingThe codes SHALL be taken from NUBC Revenue Codes Value SetFor example codes, see ExampleRevenueCenterCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Needed in the processing of institutional claims.

Comments

Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
91. ExplanationOfBenefit.item.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
BindingThe codes SHALL be taken from Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value SetFor example codes, see USCLSCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code, Bill Code, Service Code
Comments

Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40)

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
92. ExplanationOfBenefit.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
BindingThe codes SHALL be taken from Procedure Modifier Codes - AMA CPT - CMS HCPCS Value SetFor example codes, see ModifierTypeCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41)

For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
93. ExplanationOfBenefit.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Control10..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.serviced[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
94. ExplanationOfBenefit.item.serviced[x]:servicedDate
SliceNameservicedDate
Definition

The date or dates when the service or product was supplied, performed or completed.

Control10..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
95. ExplanationOfBenefit.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Must Supporttrue
Requirements

Required when the product or service code does not convey the quantity provided.

Comments

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. (42)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
96. ExplanationOfBenefit.item.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

Control0..*
TypepositiveInt
Must Supporttrue
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Comments

References number of the associated processNote entered

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
97. ExplanationOfBenefit.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
98. ExplanationOfBenefit.item.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
99. ExplanationOfBenefit.item.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set; other codes may be used where these codes are not suitableFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
100. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
SliceNameadjudicationamounttype
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
101. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
102. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Adjudication Value SetFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
103. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
Definition

Monetary amount associated with the category.

Control10..1
TypeMoney
Must Supporttrue
Requirements

Most adjuciation categories convey a monetary amount.

Comments

For example, amount submitted, eligible amount, co-payment, and benefit payable.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
104. ExplanationOfBenefit.item.adjudication:adjustmentreason
SliceNameadjustmentreason
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
105. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
106. ExplanationOfBenefit.item.adjudication:adjustmentreason.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingFor example codes, see AdjudicationValueCodes

The adjudication codes.

TypeCodeableConcept
Must Supporttrue
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="adjustmentreason"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
107. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Control10..1
BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value SetFor example codes, see AdjudicationReasonCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To support understanding of variance from adjudication expectations.

Comments

For example, may indicate that the funds for this benefit type have been exhausted.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
108. ExplanationOfBenefit.item.adjudication:allowedunits
SliceNameallowedunits
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Comments

The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
109. ExplanationOfBenefit.item.adjudication:allowedunits.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
110. ExplanationOfBenefit.item.adjudication:allowedunits.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingFor example codes, see AdjudicationValueCodes

The adjudication codes.

TypeCodeableConcept
Must Supporttrue
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="allowedunits"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
111. ExplanationOfBenefit.item.adjudication:allowedunits.value
Definition

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Control10..1
Typedecimal
Must Supporttrue
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
112. ExplanationOfBenefit.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Control10..*
TypeBackboneElement
Must Supporttrue
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
113. ExplanationOfBenefit.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
114. ExplanationOfBenefit.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Adjudication Category Discriminator Value Set; other codes may be used where these codes are not suitableFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
115. ExplanationOfBenefit.adjudication:billingnetworkstatus
SliceNamebillingnetworkstatus
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Control0..1*
TypeBackboneElement
Must Supporttrue
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Comments

Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
116. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
117. ExplanationOfBenefit.adjudication:billingnetworkstatus.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingFor example codes, see AdjudicationValueCodes

The adjudication codes.

TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="billingnetworkstatus"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
118. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Control10..1
BindingThe codes SHALL be taken from C4BB Payer Provider Network Status Value SetFor example codes, see AdjudicationReasonCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To support understanding of variance from adjudication expectations.

Comments

For example, may indicate that the funds for this benefit type have been exhausted.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
119. ExplanationOfBenefit.adjudication:benefitpaymentstatus
SliceNamebenefitpaymentstatus
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Control10..1*
TypeBackboneElement
Must Supporttrue
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Comments

Indicates the in network or out of network payment status of the claim. (142)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
120. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
121. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingFor example codes, see AdjudicationValueCodes

The adjudication codes.

TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="benefitpaymentstatus"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
122. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Control10..1
BindingThe codes SHALL be taken from C4BB Payer Benefit Payment Status Value SetFor example codes, see AdjudicationReasonCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To support understanding of variance from adjudication expectations.

Comments

For example, may indicate that the funds for this benefit type have been exhausted.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
123. ExplanationOfBenefit.adjudication:adjudicationamounttype
SliceNameadjudicationamounttype
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
124. ExplanationOfBenefit.adjudication:adjudicationamounttype.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
125. ExplanationOfBenefit.adjudication:adjudicationamounttype.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Adjudication Value SetFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
126. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
Definition

Monetary amount associated with the category.

Control10..1
TypeMoney
Must Supporttrue
Requirements

Most adjuciation categories convey a monetary amount.

Comments

For example, amount submitted, eligible amount, co-payment, and benefit payable.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
127. ExplanationOfBenefit.adjudication:adjustmentreason
SliceNameadjustmentreason
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
128. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
129. ExplanationOfBenefit.adjudication:adjustmentreason.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingFor example codes, see AdjudicationValueCodes

The adjudication codes.

TypeCodeableConcept
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator"/>
    <code value="adjustmentreason"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
130. ExplanationOfBenefit.adjudication:adjustmentreason.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Control10..1
BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value SetFor example codes, see AdjudicationReasonCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To support understanding of variance from adjudication expectations.

Comments

Reason codes used to interpret the Non-Covered Amount that are provided to the Provider. (92)

For example, may indicate that the funds for this benefit type have been exhausted.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
131. ExplanationOfBenefit.total
Definition

Categorized monetary totals for the adjudication.

Control10..*
TypeBackboneElement
Must Supporttrue
Requirements

To provide the requestor with financial totals by category for the adjudication.

Comments

Totals for amounts submitted, co-pays, benefits payable etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.total. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
132. ExplanationOfBenefit.total.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
133. ExplanationOfBenefit.total.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Total Category Discriminator Value Set; other codes may be used where these codes are not suitableFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Needed to convey the type of total provided.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
134. ExplanationOfBenefit.total.amount
Definition

Monetary total amount associated with the category.

Control1..1
TypeMoney
Requirements

Needed to convey the total monetary amount.

Comments

Total amount for each category (i.e., submitted, allowed, etc.) (148)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
135. ExplanationOfBenefit.total:adjudicationamounttype
SliceNameadjudicationamounttype
Definition

Categorized monetary totals for the adjudication.

Control10..*
TypeBackboneElement
Must Supporttrue
Requirements

To provide the requestor with financial totals by category for the adjudication.

Comments

Describes the various amount fields used when payers receive and adjudicate a claim. (187)

Totals for amounts submitted, co-pays, benefits payable etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
136. ExplanationOfBenefit.total:adjudicationamounttype.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
137. ExplanationOfBenefit.total:adjudicationamounttype.category
Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Control1..1
BindingThe codes SHALL be taken from C4BB Adjudication Value SetFor example codes, see AdjudicationValueCodes
TypeCodeableConcept
Requirements

Needed to convey the type of total provided.

Comments

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
138. ExplanationOfBenefit.total:adjudicationamounttype.amount
Definition

Monetary total amount associated with the category.

Control1..1
TypeMoney
Must Supporttrue
Requirements

Needed to convey the total monetary amount.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
139. ExplanationOfBenefit.payment
Definition

Payment details for the adjudication of the claim.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
140. ExplanationOfBenefit.payment.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
141. ExplanationOfBenefit.payment.type
Definition

Whether this represents partial or complete payment of the benefits payable.

Control0..1
BindingThe codes SHALL be taken from C4BB Payer Claim Payment Status Code Value SetFor example codes, see ExamplePaymentTypeCodes
TypeCodeableConcept
Must Supporttrue
Requirements

To advise the requestor when the insurer believes all payments to have been completed.

Comments

Indicates whether the claim was paid or denied. (91)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
142. ExplanationOfBenefit.payment.date
Definition

Estimated date the payment will be issued or the actual issue date of payment.

Control0..1
Typedate
Must Supporttrue
Requirements

To advise the payee when payment can be expected.

Comments

The date the claim was paid. (107)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
143. ExplanationOfBenefit.processNote
Definition

A note that describes or explains adjudication results in a human readable form.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Provides the insurer specific textual explanations associated with the processing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
144. ExplanationOfBenefit.processNote.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
145. ExplanationOfBenefit.processNote.text
Definition

The explanation or description associated with the processing.

Control0..1
Typestring
Must Supporttrue
Requirements

Required to provide human readable explanation.

Comments

Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
1. ExplanationOfBenefit
Definition

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

Control0..*
Alternate NamesEOB
2. ExplanationOfBenefit.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. ExplanationOfBenefit.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control1..1
TypeMeta
Must Supporttrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. ExplanationOfBenefit.meta.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
5. ExplanationOfBenefit.meta.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ExplanationOfBenefit.meta.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
6. ExplanationOfBenefit.meta.versionId
Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Control0..1
Typeid
Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. ExplanationOfBenefit.meta.lastUpdated
Definition

When the resource last changed - e.g. when the version changed.

Control1..1
Typeinstant
Must Supporttrue
Comments

Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
8. ExplanationOfBenefit.meta.source
Definition

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

Control0..1
Typeuri
Comments

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. ExplanationOfBenefit.meta.profile
Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Control1..*
Typecanonical(StructureDefinition))
Comments

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. CPCDS data element (190)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. ExplanationOfBenefit.meta.security
Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Control0..*
BindingThe codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable Security Labels from the Healthcare Privacy and Security Classification System
TypeCoding
Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. ExplanationOfBenefit.meta.tag
Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Control0..*
BindingFor example codes, see CommonTags Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
TypeCoding
Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. ExplanationOfBenefit.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. ExplanationOfBenefit.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. ExplanationOfBenefit.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
TypeNarrative
Alternate Namesnarrativehtmlxhtmldisplay
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. ExplanationOfBenefit.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resourcesanonymous resourcescontained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

16. ExplanationOfBenefit.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
17. ExplanationOfBenefit.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
18. ExplanationOfBenefit.identifier
Definition

A unique identifier assigned to this explanation of benefit.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
TypeIdentifier
Must Supporttrue
Requirements

Allows EOBs to be distinguished and referenced.

Comments

Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ type
19. ExplanationOfBenefit.identifier:uniqueclaimid
SliceNameuniqueclaimid
Definition

A unique identifier assigned to this explanation of benefit.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..1
TypeIdentifier
Must Supporttrue
Requirements

Allows EOBs to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. ExplanationOfBenefit.identifier:uniqueclaimid.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
21. ExplanationOfBenefit.identifier:uniqueclaimid.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
22. ExplanationOfBenefit.identifier:uniqueclaimid.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse Identifies the purpose for this identifier, if known
Typecode
Is Modifiertrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. ExplanationOfBenefit.identifier:uniqueclaimid.type
Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Control1..1
BindingThe codes SHALL be taken from Identifier Type Codes; other codes may be used where these codes are not suitable A coded type for an identifier that can be used to determine which identifier to use for a specific purpose
TypeCodeableConcept
Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType"/>
    <code value="uc"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. ExplanationOfBenefit.identifier:uniqueclaimid.system
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Control0..1
Typeuri
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Comments

Identifier.system is always case sensitive.

Example
General:http://www.acme.com/identifiers/patient
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. ExplanationOfBenefit.identifier:uniqueclaimid.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Control1..1
Typestring
Must Supporttrue
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Example
General:123456
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. ExplanationOfBenefit.identifier:uniqueclaimid.period
Definition

Time period during which identifier is/was valid for use.

Control0..1
TypePeriod
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. ExplanationOfBenefit.identifier:uniqueclaimid.assigner
Definition

Organization that issued/manages the identifier.

Control0..1
TypeReference(Organization))
Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. ExplanationOfBenefit.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from ExplanationOfBenefitStatus A code specifying the state of the resource instance
Typecode
Is Modifiertrue
Must Supporttrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. ExplanationOfBenefit.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Control1..1
BindingThe codes SHALL be taken from ClaimTypeCodes
TypeCodeableConcept
Must Supporttrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Comments

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
    <code value="institutional"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. ExplanationOfBenefit.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Control1..1
BindingThe codes SHALL be taken from C4BB Institutional Claim SubType Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType"/>
    <code value="outpatient"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. ExplanationOfBenefit.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Control1..1
BindingThe codes SHALL be taken from Use Complete, proposed, exploratory, other
Typecode
Must Supporttrue
Requirements

This element is required to understand the nature of the request for adjudication.

Comments

Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations

Pattern Valueclaim
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. ExplanationOfBenefit.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

Control1..1
TypeReference(C4BBPatient))
Must Supporttrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Comments

Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. ExplanationOfBenefit.billablePeriod
Definition

The period for which charges are being submitted.

Control1..1
TypePeriod
Must Supporttrue
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. ExplanationOfBenefit.billablePeriod.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
35. ExplanationOfBenefit.billablePeriod.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ExplanationOfBenefit.billablePeriod.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
36. ExplanationOfBenefit.billablePeriod.start
Definition

The start of the period. The boundary is inclusive.

Control1..1 This element is affected by the following invariants: per-1
TypedateTime
Must Supporttrue
Comments

The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. ExplanationOfBenefit.billablePeriod.end
Definition

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

Control0..1 This element is affected by the following invariants: per-1
TypedateTime
Comments

The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)

Meaning if MissingIf the end of the period is missing, it means that the period is ongoing
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. ExplanationOfBenefit.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Must Supporttrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Comments

Date the claim was adjudicated (179)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. ExplanationOfBenefit.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

Control0..1
TypeReference(PractitionerPractitionerRole))
Requirements

Some jurisdictions require the contact information for personnel completing claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. ExplanationOfBenefit.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Control1..1
TypeReference(C4BBOrganization))
Must Supporttrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Comments

Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. ExplanationOfBenefit.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

Control1..1
TypeReference(C4BBOrganization))
Must Supporttrue
Comments

The identifier assigned to the Billing Provider. (94)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

Control0..1
BindingThe codes SHALL be taken from ProcessPriorityCodes
TypeCodeableConcept
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
43. ExplanationOfBenefit.fundsReserveRequested
Definition

A code to indicate whether and for whom funds are to be reserved for future claims.

Control0..1
BindingFor example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None)
TypeCodeableConcept
Requirements

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Alternate NamesFund pre-allocation
Comments

This field is only used for preauthorizations.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. ExplanationOfBenefit.fundsReserve
Definition

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Control0..1
BindingFor example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None)
TypeCodeableConcept
Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Comments

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. ExplanationOfBenefit.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Comments

If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.related.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
47. ExplanationOfBenefit.related.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
48. ExplanationOfBenefit.related.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
49. ExplanationOfBenefit.related.claim
Definition

Reference to a related claim.

Control0..1
TypeReference(Claim))
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. ExplanationOfBenefit.related.relationship
Definition

A code to convey how the claims are related.

Control1..1
BindingThe codes SHALL be taken from C4BB Related Claim Relationship Codes Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
51. ExplanationOfBenefit.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Control1..1
TypeIdentifier
Must Supporttrue
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Comments

For example, Property/Casualty insurer claim number or Workers Compensation case number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
52. ExplanationOfBenefit.prescription
Definition

Prescription to support the dispensing of pharmacy, device or vision products.

Control0..1
TypeReference(MedicationRequestVisionPrescription))
Requirements

Required to authorize the dispensing of controlled substances and devices.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
53. ExplanationOfBenefit.originalPrescription
Definition

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Control0..1
TypeReference(MedicationRequest))
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Comments

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. ExplanationOfBenefit.payee
Definition

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

InvariantsDefined on this element
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required (: type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists())
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. ExplanationOfBenefit.payee.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
56. ExplanationOfBenefit.payee.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
57. ExplanationOfBenefit.payee.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
58. ExplanationOfBenefit.payee.type
Definition

Type of Party to be reimbursed: Subscriber, provider, other.

Control1..1
BindingThe codes SHALL be taken from C4BB Payee Type Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Comments

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
59. ExplanationOfBenefit.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Control0..1
TypeReference(C4BBOrganizationC4BBPatientC4BBPractitionerC4BBRelatedPerson))
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Comments

Recipient reference (121)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
60. ExplanationOfBenefit.referral
Definition

A reference to a referral resource.

Control0..1
TypeReference(ServiceRequest))
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments

The referral resource which lists the date, practitioner, reason and other supporting information.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
61. ExplanationOfBenefit.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(Location))
Requirements

Insurance adjudication can be dependant on where services were delivered.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. ExplanationOfBenefit.claim
Definition

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

Control0..1
TypeReference(Claim))
Requirements

To provide a link to the original adjudication request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
63. ExplanationOfBenefit.claimResponse
Definition

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

Control0..1
TypeReference(ClaimResponse))
Requirements

To provide a link to the original adjudication response.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
64. ExplanationOfBenefit.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes The result of the claim processing
Typecode
Must Supporttrue
Requirements

To advise the requestor of an overall processing outcome.

Comments

Expected value is complete

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
65. ExplanationOfBenefit.disposition
Definition

A human readable description of the status of the adjudication.

Control0..1
Typestring
Requirements

Provided for user display.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
66. ExplanationOfBenefit.preAuthRef
Definition

Reference from the Insurer which is used in later communications which refers to this adjudication.

Control0..*
Typestring
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Comments

This value is only present on preauthorization adjudications.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
67. ExplanationOfBenefit.preAuthRefPeriod
Definition

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

Control0..*
TypePeriod
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Comments

This value is only present on preauthorization adjudications.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
68. ExplanationOfBenefit.careTeam
Definition

The members of the team who provided the products and services.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Common to identify the responsible and supporting practitioners.

InvariantsDefined on this element
EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set (: where(role.where(coding.code in ('rendering')).exists().not() or qualification.memberOf('http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066')).exists())
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization (: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) ))
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner (: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) ))
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
69. ExplanationOfBenefit.careTeam.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
70. ExplanationOfBenefit.careTeam.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
71. ExplanationOfBenefit.careTeam.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
72. ExplanationOfBenefit.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Comments

careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
73. ExplanationOfBenefit.careTeam.provider
Definition

Member of the team who provided the product or service.

Control1..1
TypeReference(C4BBOrganizationC4BBPractitioner))
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Often a regulatory requirement to specify the responsible provider.

Comments

The identifier assigned to the care team. (varies depending on the profile)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
74. ExplanationOfBenefit.careTeam.responsible
Definition

The party who is billing and/or responsible for the claimed products or services.

Control0..1
Typeboolean
Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Comments

Responsible might not be required when there is only a single provider listed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
75. ExplanationOfBenefit.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Control1..1
BindingThe codes SHALL be taken from C4BB Claim Institutional Care Team Role Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

The functional role of a provider on a claim. (165)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
76. ExplanationOfBenefit.careTeam.qualification
Definition

The qualification of the practitioner which is applicable for this service.

Control0..1
BindingThe codes SHALL be taken from Healthcare Provider Taxonomy
TypeCodeableConcept
Requirements

Need to specify which qualification a provider is delivering the product or service under.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
77. ExplanationOfBenefit.supportingInfo
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..*
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Defines data elements not available in the base EOB resource

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • pattern @ category
78. ExplanationOfBenefit.supportingInfo.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
79. ExplanationOfBenefit.supportingInfo.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
80. ExplanationOfBenefit.supportingInfo.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
81. ExplanationOfBenefit.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
82. ExplanationOfBenefit.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
83. ExplanationOfBenefit.supportingInfo.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
BindingFor example codes, see ExceptionCodes The valuset used for additional information codes
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
84. ExplanationOfBenefit.supportingInfo.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
85. ExplanationOfBenefit.supportingInfo.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
86. ExplanationOfBenefit.supportingInfo.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
87. ExplanationOfBenefit.supportingInfo:clmrecvddate
SliceNameclmrecvddate
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

The date the claim was received by the payer (88)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
88. ExplanationOfBenefit.supportingInfo:clmrecvddate.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
89. ExplanationOfBenefit.supportingInfo:clmrecvddate.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
90. ExplanationOfBenefit.supportingInfo:clmrecvddate.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
91. ExplanationOfBenefit.supportingInfo:clmrecvddate.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
92. ExplanationOfBenefit.supportingInfo:clmrecvddate.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="clmrecvddate"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
93. ExplanationOfBenefit.supportingInfo:clmrecvddate.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
BindingFor example codes, see ExceptionCodes The valuset used for additional information codes
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
94. ExplanationOfBenefit.supportingInfo:clmrecvddate.timing[x]
Definition

The date when or period to which this information refers.

Control1..1
Typedate
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
95. ExplanationOfBenefit.supportingInfo:clmrecvddate.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
96. ExplanationOfBenefit.supportingInfo:clmrecvddate.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
97. ExplanationOfBenefit.supportingInfo:typeofbill
SliceNametypeofbill
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of institution, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
98. ExplanationOfBenefit.supportingInfo:typeofbill.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
99. ExplanationOfBenefit.supportingInfo:typeofbill.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
100. ExplanationOfBenefit.supportingInfo:typeofbill.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
101. ExplanationOfBenefit.supportingInfo:typeofbill.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
102. ExplanationOfBenefit.supportingInfo:typeofbill.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="typeofbill"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
103. ExplanationOfBenefit.supportingInfo:typeofbill.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control1..1
BindingThe codes SHALL be taken from NUBC Type of Bill Codes Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
104. ExplanationOfBenefit.supportingInfo:typeofbill.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
105. ExplanationOfBenefit.supportingInfo:typeofbill.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
106. ExplanationOfBenefit.supportingInfo:typeofbill.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
107. ExplanationOfBenefit.supportingInfo:pointoforigin
SliceNamepointoforigin
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Identifies the place where the patient was identified as needing admission to an institution. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
108. ExplanationOfBenefit.supportingInfo:pointoforigin.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
109. ExplanationOfBenefit.supportingInfo:pointoforigin.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
110. ExplanationOfBenefit.supportingInfo:pointoforigin.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
111. ExplanationOfBenefit.supportingInfo:pointoforigin.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
112. ExplanationOfBenefit.supportingInfo:pointoforigin.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="pointoforigin"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
113. ExplanationOfBenefit.supportingInfo:pointoforigin.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control1..1
BindingThe codes SHALL be taken from NUBC Point Of Origin Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
114. ExplanationOfBenefit.supportingInfo:pointoforigin.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
115. ExplanationOfBenefit.supportingInfo:pointoforigin.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
116. ExplanationOfBenefit.supportingInfo:pointoforigin.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
117. ExplanationOfBenefit.supportingInfo:admtype
SliceNameadmtype
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Priority of the admission. Information located on (UB04 Form Locator 14). For example, an admission type of elective indicates that the patient's condition permitted time for medical services to be scheduled. (14)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
118. ExplanationOfBenefit.supportingInfo:admtype.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
119. ExplanationOfBenefit.supportingInfo:admtype.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
120. ExplanationOfBenefit.supportingInfo:admtype.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
121. ExplanationOfBenefit.supportingInfo:admtype.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
122. ExplanationOfBenefit.supportingInfo:admtype.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="admtype"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
123. ExplanationOfBenefit.supportingInfo:admtype.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control1..1
BindingThe codes SHALL be taken from NUBC Priority (Type) of Admission or Visit Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
124. ExplanationOfBenefit.supportingInfo:admtype.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
125. ExplanationOfBenefit.supportingInfo:admtype.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
126. ExplanationOfBenefit.supportingInfo:admtype.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
127. ExplanationOfBenefit.supportingInfo:discharge-status
SliceNamedischarge-status
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Patient’s status as of the discharge date for a facility stay. Information located on UB04. (Form Locator 17). (117)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
128. ExplanationOfBenefit.supportingInfo:discharge-status.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
129. ExplanationOfBenefit.supportingInfo:discharge-status.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
130. ExplanationOfBenefit.supportingInfo:discharge-status.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
131. ExplanationOfBenefit.supportingInfo:discharge-status.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
132. ExplanationOfBenefit.supportingInfo:discharge-status.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="discharge-status"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
133. ExplanationOfBenefit.supportingInfo:discharge-status.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control1..1
BindingThe codes SHALL be taken from NUBC Patient Discharge Status Codes Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
134. ExplanationOfBenefit.supportingInfo:discharge-status.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
135. ExplanationOfBenefit.supportingInfo:discharge-status.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
136. ExplanationOfBenefit.supportingInfo:discharge-status.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
137. ExplanationOfBenefit.supportingInfo:medicalrecordnumber
SliceNamemedicalrecordnumber
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Provider submitted medical record number that can be included on the claim. (109)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
138. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
139. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
140. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
141. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
142. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="medicalrecordnumber"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
143. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
BindingFor example codes, see ExceptionCodes The valuset used for additional information codes
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
144. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
145. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control1..1
Typestring
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
146. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.value[x]:valueString
SliceNamevalueString
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control1..1
Typestring
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
147. ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
148. ExplanationOfBenefit.supportingInfo:patientaccountnumber
SliceNamepatientaccountnumber
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..1
TypeBackboneElement
Must Supporttrue
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Provider assigned patient account number that can be included on the claim. (109)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
149. ExplanationOfBenefit.supportingInfo:patientaccountnumber.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
150. ExplanationOfBenefit.supportingInfo:patientaccountnumber.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
151. ExplanationOfBenefit.supportingInfo:patientaccountnumber.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
152. ExplanationOfBenefit.supportingInfo:patientaccountnumber.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Comments

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
153. ExplanationOfBenefit.supportingInfo:patientaccountnumber.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingThe codes SHALL be taken from C4BB SupportingInfo Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Pattern Value<valueCodeableConcept xmlns="http://hl7.org/fhir">
  <coding>
    <system value="http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType"/>
    <code value="patientaccountnumber"/>
  </coding>
</valueCodeableConcept>
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
154. ExplanationOfBenefit.supportingInfo:patientaccountnumber.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
BindingFor example codes, see ExceptionCodes The valuset used for additional information codes
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
155. ExplanationOfBenefit.supportingInfo:patientaccountnumber.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
156. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control1..1
Typestring
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on ExplanationOfBenefit.supportingInfo.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • type @ $this
157. ExplanationOfBenefit.supportingInfo:patientaccountnumber.value[x]:valueString
SliceNamevalueString
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control1..1
Typestring
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
158. ExplanationOfBenefit.supportingInfo:patientaccountnumber.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth
TypeCoding
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
159. ExplanationOfBenefit.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Control1..*
TypeBackboneElement
Requirements

Required for the adjudication by provided context for the services and product listed.

Comments

Diagnosis codes describe an individual's disease or medical condition. (6, 7, 8, 21, 22, 23, 30)

160. ExplanationOfBenefit.diagnosis.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
161. ExplanationOfBenefit.diagnosis.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
162. ExplanationOfBenefit.diagnosis.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensionsuser contentmodifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
163. ExplanationOfBenefit.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Comments

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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
164. ExplanationOfBenefit.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Control1..1
BindingThe codes SHALL be taken from Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set
TypeCodeableConcept
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Requirements

Provides health context for the evaluation of the products and/or services.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
165. ExplanationOfBenefit.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Control1..1
BindingThe codes SHALL be taken from C4BB Claim Outpatient Institutional Diagnosis Type Value Set
TypeCodeableConcept
Must Supporttrue
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit. (21, 22, 23)

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
166. ExplanationOfBenefit.diagnosis.onAdmission
Definition

Indication of whether the diagnosis was present on admission to a facility.

Control0..1
BindingFor example codes, see ExampleDiagnosisOnAdmissionCodes Present on admission
TypeCodeableConcept
Requirements

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

InvariantsDefined on this element