CARIN Consumer Directed Payer Data Exchange
0.1.3 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.1.3). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BBExplanationOfBenefitProfessionalNonClinician

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.

The official URL for this profile is:

http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 2 elements (9 nested mandatory elements)
Must-Support: 22 elements

Slices

This structure defines the following Slices:

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

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... identifier S1..*IdentifierClaim identifier for a claim. (35)
... status S1..1codeactive | cancelled | draft | entered-in-error
... type 1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: professional
... provider 1..1Reference(C4BB Organization | C4BB Practitioner)The National Provider Identifier assigned to the Billing Provider. (94)
... payee
.... type 1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120)
.... party 1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference (121)
... facility S0..1Reference(Location)The NPI of the facility where the services were rendered. (97)
... careTeam I0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
EOB-prof-careTeam-organization: Professional EOB: Careteam roles refer to an organization
.... provider 1..1Reference(C4BB Organization | C4BB Practitioner)The NPI of the referring physician. (99)
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. (101)
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
...... coding 1..1CodingCode defined by a terminology system
..... code 1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:performingnetworkcontractingstatus 0..1BackboneElementIndicates that the Performing Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. (101)
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:claimrecvddate 0..1BackboneElementThe date the claim was received by the payer (88)
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: claimrecvddate
..... timing[x] 1..1dateWhen it occurred
.... supportingInfo:servicefacility 0..1BackboneElementService Facility
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... value[x] 1..1(Slice Definition)Data to be provided
Slice: Unordered, Open by type:$this
..... valueReference 1..1Reference(Organization)Data to be provided
... diagnosis S1..*BackboneElementThe member's principal condition treated on the claim (837P Data Element HI01 or CMS 1500 Item 21A). Decimals will be included. (22)
.... diagnosis[x] S1..1CodeableConceptA plain text representation of the diagnosis (145)
Binding: ICD-10-CM Diagnosis Codes (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
... insurance 1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141)
.... coverage 1..1Reference(C4BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1)
... item
.... sequence S1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36)
.... productOrService S1..1CodeableConceptA plain text representation of the CPT / HCPCS procedure (147)
Binding: AMA CPT CMS HCPCS Procedure Codes (required)
.... modifier S0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41)
Binding: AMA CPT CMS HCPCS Modifiers (required)
.... servicedPeriod S0..1PeriodDate services began/ended. Located on CMS 1500 (Form Locator 24A) (118)
.... location[x] S0..1(Slice Definition)Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. (46)
Slice: Unordered, Open by type:$this
.... locationCodeableConcept S0..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity S0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42)
.... adjudication 1..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by pattern:category
..... adjudication:adjudicationamounttype 0..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount S0..1MoneyMonetary amount
..... adjudication:denialreason 0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategory
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC) (required)
..... adjudication:inoutnetwork 1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
..... adjudication:allowedunits 0..1BackboneElementThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategory
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... total 0..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
..... amount S1..1MoneyTotal amount for each category (i.e., submitted, allowed, etc.) (148)
.... total:adjudicationamounttype S0..*BackboneElementAmounts
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... type S0..1CodeableConceptIndicates whether the claim was paid or denied. (91)
.... date S0..1dateThe date the claim was paid. (107)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*IdentifierClaim identifier for a claim. (35)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!ΣI0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type SΣI1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system ΣI0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value ΣI0..1stringThe value that is unique
Example General: 123456
.... period ΣI0..1PeriodTime period when id is/was valid for use
.... assigner ΣI0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣI1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type SΣI1..1CodeableConceptSpecifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16)
Binding: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: professional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use ΣI1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣI1..1Reference(C4BB Patient)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1)
... billablePeriod SΣI0..1PeriodRelevant time frame for the claim
... created ΣI1..1dateTimeResponse creation date
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣI1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣI1..1Reference(C4BB Organization | C4BB Practitioner)The National Provider Identifier assigned to the Billing Provider. (94)
... priority I0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related SI0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship SI1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference I0..1IdentifierFile or case reference
... prescription I0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription I0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SI1..1CodeableConceptIdentifies recipient of benefits payable; i.e., provider or subscriber (120)
Binding: Claim Payee Type Codes (required)
.... party SI1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference (121)
... referral I0..1Reference(ServiceRequest)Treatment Referral
... facility SI0..1Reference(Location)The NPI of the facility where the services were rendered. (97)
... claim I0..1Reference(Claim)Claim reference
... claimResponse I0..1Reference(ClaimResponse)Claim response reference
... outcome ΣI1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition I0..1stringDisposition Message
... preAuthRef I0..*stringPreauthorization reference
... preAuthRefPeriod I0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
EOB-prof-careTeam-organization: Professional EOB: Careteam roles refer to an organization
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntOrder of care team
.... provider SI1..1Reference(C4BB Organization | C4BB Practitioner)The NPI of the referring physician. (99)
.... responsible SI0..1booleanIndicator of the lead practitioner
.... role SI1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification SI0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo SI0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:billingnetworkcontractingstatus SI0..1BackboneElementIndicates that the Billing Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. (101)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding ΣI1..1CodingCode defined by a terminology system
...... text ΣI0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:performingnetworkcontractingstatus SI0..1BackboneElementIndicates that the Performing Provider has a contract with the Plan (regardless of the network) that is effective on the date of service or admission. (101)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:claimrecvddate SI0..1BackboneElementThe date the claim was received by the payer (88)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: claimrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1dateWhen it occurred
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:servicefacility SI0..1BackboneElementService Facility
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategory
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI1..1(Slice Definition)Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference SI1..1Reference(Organization)Data to be provided
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis SI1..*BackboneElementThe member's principal condition treated on the claim (837P Data Element HI01 or CMS 1500 Item 21A). Decimals will be included. (22)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] SI1..1CodeableConceptA plain text representation of the diagnosis (145)
Binding: ICD-10-CM Diagnosis Codes (required)
.... type SI1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
.... onAdmission I0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure SI0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type SI0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date SI0..1dateTimeWhen the procedure was performed
.... procedure[x] I1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi I0..*Reference(Device)Unique device identifier
... precedence I0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SΣI1..*BackboneElementIdentifies the primary payer. For use only on secondary claims. (141)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣI1..1booleanCoverage to be used for adjudication
.... coverage SΣI1..1Reference(C4BB Coverage)Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1)
.... preAuthRef I0..*stringPrior authorization reference number
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I0..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SI1..1positiveIntLine identification number that represents the number assigned in a source system for identification and processing. (36)
.... careTeamSequence I0..*positiveIntApplicable care team members
.... diagnosisSequence I0..*positiveIntApplicable diagnoses
.... procedureSequence I0..*positiveIntApplicable procedures
.... informationSequence I0..*positiveIntApplicable exception and supporting information
.... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
.... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService SI1..1CodeableConceptA plain text representation of the CPT / HCPCS procedure (147)
Binding: AMA CPT CMS HCPCS Procedure Codes (required)
.... modifier SI0..*CodeableConceptModifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41)
Binding: AMA CPT CMS HCPCS Modifiers (required)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1(Slice Definition)Date or dates of service or product delivery
Slice: Unordered, Closed by type:$this
..... serviced[x]:servicedPeriod SI0..1PeriodDate services began/ended. Located on CMS 1500 (Form Locator 24A) (118)
.... location[x] SI0..1(Slice Definition)Code indicating the location, such as inpatient, outpatient facility, office, or home health agency, where this service was performed. (46)
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
..... location[x]:locationCodeableConcept SI0..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity SI0..1SimpleQuantityThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42)
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber SI0..*positiveIntReferences number of the associated processNote
.... adjudication SI1..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype SI0..*BackboneElementAmounts
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount SI0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:denialreason SI0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategory
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason SI1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC) (required)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:inoutnetwork SI1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:allowedunits SI0..1BackboneElementThe quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category SI1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategory
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntProduct or service provided
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*See adjudicationDetail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntProduct or service provided
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*See adjudicationSubdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence I0..*positiveIntItem sequence number
.... detailSequence I0..*positiveIntDetail sequence number
.... subDetailSequence I0..*positiveIntSubdetail sequence number
.... provider I0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity I0..1SimpleQuantityCount of products or services
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication I0..*See adjudicationAdded items adjudication
.... detail I0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... noteNumber