CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0 - STU 2.1 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Professional NonClinician

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician Version: 2.1.0
Standards status: Trial-use Computable Name: C4BBExplanationOfBenefitProfessionalNonClinician

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision 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 profile has requirements for financial data.

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total If there is a mix of lines paid in network and out of network on a claim, the value of C4BB Payer Benefit Payment Status is ‘Other’
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indicate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
  • .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
  • .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
  • .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
  • .item.productOrService:   CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on a professional / non-clinician claim . The cardinality of the HL7 base EOB Resource for .item.revenue is 1..1 if .item is provided. Since item.productOrService is required it means that .item.revenue must be populated. Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason for item.revenue.
  • A CPT / HCPCS code may not be available on a professional nonclinician vision claim (vision only). The cardinality of the HL7 base EOB Resource for item.productOrService is 1..1 if .item is provided.  Since .item.revenue is required it means that item.productOrService must be populated.  Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason when a CPT / HCPCS or code is not available.
  • Every supportingInfo repetitions with a Transportation Services Category code need to be associated with at least one line item by referencing supportingInfo.sequence through .item.informationSequence.
  • item.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the line
  • .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • ExplanationOfBenefit.adjudication elements may contain slices for both billing network status (billingnetworkstatus) or rendering network status (renderingnetworkstatus). ExplanationOfBenefit.adjudication and ExplanationOfBenefit.item.adjudication elements may contain slices for benefit payment status (benefitpaymentstatus). Each of these adjudication slices contain a reason code bound to very similar ValueSets that indicate network status. The billing or rendering network status indicates the general relationship (often a contract status) the provider has with the payer. The benefit payment status indicates how the service or product (either at the header or item level) is covered (in or out of network) in context to its provisioning. These values may be different across adjudication slices.
    An example of this is where an in network provider that has billed for a service that is not within the scope of the contract of service with the payer.
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefitProfessionalNonClinicianBasis

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource
EOB-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
... item
.... adjudication 2..* BackboneElement Adjudication details
.... Slices for adjudication Content/Rules for all slices
..... adjudication:adjudicationamounttype S 1..* BackboneElement Amounts
...... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S 1..1 Money Monetary amount
... Slices for total S 1..* BackboneElement Adjudication totals
Slice: Unordered, Open by value:category
.... total:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (extensible)
..... amount 1..1 Money Financial total for the category
.... total:adjudicationamounttype S 1..* BackboneElement Total adjudication type and amount
..... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.total.categoryextensibleC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-professional-nonclinician-meta-profile-versionwarningExplanationOfBenefitProfessional and Nonclinician 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-Professional-NonClinician|2.1'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
EOB-prof-all-transportation-supportinginfo-linked-to-line: Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
EOB-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
... meta SΣ 1..1 Meta Metadata about the resource
ele-1: All FHIR elements must have a @value or children
.... lastUpdated SΣ 1..1 instant When the resource version last changed
ele-1: All FHIR elements must have a @value or children
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
ele-1: All FHIR elements must have a @value or children
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
..... value SΣ 1..1 string Unique Claim Identifier
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


ele-1: All FHIR elements must have a @value or children
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
ele-1: All FHIR elements must have a @value or children
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... related S 0..* BackboneElement Prior or corollary claims
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... reference S 1..1 Identifier File or case reference
ele-1: All FHIR elements must have a @value or children
... payee SC 0..1 BackboneElement Recipient of benefits payable
ele-1: All FHIR elements must have a @value or children
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
ele-1: All FHIR elements must have a @value or children
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... careTeam SC 0..* BackboneElement Care Team members
ele-1: All FHIR elements must have a @value or children
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Order of care team
ele-1: All FHIR elements must have a @value or children
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
ele-1: All FHIR elements must have a @value or children
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
ele-1: All FHIR elements must have a @value or children
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
ele-1: All FHIR elements must have a @value or children
...... value[x]:valueString S 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
..... value[x] 1..1 Quantity Data to be provided
ele-1: All FHIR elements must have a @value or children
...... value Σ 1..1 decimal Numerical value (with implicit precision)
ele-1: All FHIR elements must have a @value or children
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.


ele-1: All FHIR elements must have a @value or children
...... unit Σ 0..1 string Unit representation
ele-1: All FHIR elements must have a @value or children
Required Pattern: [lb_av]
...... system ΣC 0..1 uri System that defines coded unit form
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
..... value[x] 1..1 Quantity Data to be provided
ele-1: All FHIR elements must have a @value or children
...... value Σ 1..1 decimal Numerical value (with implicit precision)
ele-1: All FHIR elements must have a @value or children
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.


ele-1: All FHIR elements must have a @value or children
...... unit Σ 0..1 string Unit representation
ele-1: All FHIR elements must have a @value or children
Required Pattern: [mi_i]
...... system ΣC 0..1 uri System that defines coded unit form
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
..... value[x] 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
..... value[x] 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
..... value[x] 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... sequence 1..1 positiveInt Information instance identifier
ele-1: All FHIR elements must have a @value or children
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
..... value[x] 1..1 string Data to be provided
ele-1: All FHIR elements must have a @value or children
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Diagnosis instance identifier
ele-1: All FHIR elements must have a @value or children
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
ele-1: All FHIR elements must have a @value or children
... insurance SΣC 1..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
... item S 1..* BackboneElement Product or service provided
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence S 1..1 positiveInt Item instance identifier
ele-1: All FHIR elements must have a @value or children
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... serviced[x] 1..1 Date or dates of service or product delivery
ele-1: All FHIR elements must have a @value or children
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... noteNumber S 0..* positiveInt Applicable note numbers
ele-1: All FHIR elements must have a @value or children
.... Slices for adjudication S 2..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... adjudication:adjustmentreason S 0..1 BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
ele-1: All FHIR elements must have a @value or children
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
ele-1: All FHIR elements must have a @value or children
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
..... adjudication:adjudicationamounttype S 1..* BackboneElement Amounts
ele-1: All FHIR elements must have a @value or children
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
ele-1: All FHIR elements must have a @value or children
...... amount S 1..1 Money Monetary amount
ele-1: All FHIR elements must have a @value or children
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
ele-1: All FHIR elements must have a @value or children
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
ele-1: All FHIR elements must have a @value or children
... Slices for total SΣ 1..* BackboneElement Adjudication totals
Slice: Unordered, Open by value:category
ele-1: All FHIR elements must have a @value or children
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (extensible)
ele-1: All FHIR elements must have a @value or children
..... amount Σ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
.... total:adjudicationamounttype SΣ 1..* BackboneElement Total adjudication type and amount
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Value Set (required)
ele-1: All FHIR elements must have a @value or children
..... amount Σ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
... payment S 0..1 BackboneElement Payment Details
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
ele-1: All FHIR elements must have a @value or children
... processNote S 0..* BackboneElement Note concerning adjudication
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typerequiredC4BBProfessionalAndNonClinicianClaimType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBProfessionalAndNonClinicianClaimType
from this IG
ExplanationOfBenefit.userequiredPattern: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBRelatedClaimRelationshipCodes
from this IG
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayeeType
from this IG
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianCareTeamRole
from this IG
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcare Provider Taxonomy . (a valid code from http://nucc.org/provider-taxonomy)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientweight.categoryextensiblePattern: patientweight
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:patientweight.value[x].comparatorrequiredQuantityComparator
http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:ambulancetransportreason.categoryextensiblePattern: ambulancetransportreason
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:ambulancetransportreason.reasonrequiredC4BBAmbulanceTransportReasonCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAmbulanceTransportReasonCodes
from this IG
ExplanationOfBenefit.supportingInfo:transportationdistance.categoryextensiblePattern: transportationdistance
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:transportationdistance.value[x].comparatorrequiredQuantityComparator
http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1
from the FHIR Standard
ExplanationOfBenefit.supportingInfo:roudtrippurpose.categoryextensiblePattern: roudtrippurpose
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:stretcherpurpose.categoryextensiblePattern: stretcherpurpose
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:pickuplocation.categoryextensiblePattern: pickuplocation
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.supportingInfo:dropofflocation.categoryextensiblePattern: dropofflocation
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBSupportingInfoType
from this IG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CDCICD910CMDiagnosisCodes
from this IG
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBClaimProfessionalAndNonClinicianDiagnosisType
from this IG
ExplanationOfBenefit.item.productOrServicerequiredAMACPTCMSHCPCSProcedureCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSProcedureCodes
from this IG
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
http://hl7.org/fhir/us/carin-bb/ValueSet/AMACPTCMSHCPCSModifiers
from this IG
ExplanationOfBenefit.item.location[x]requiredCMSPlaceofServiceCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/CMSPlaceofServiceCodes
from this IG
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/carin-bb/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerProviderNetworkStatus
from this IG
ExplanationOfBenefit.total.categoryextensibleC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
from this IG
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerClaimPaymentStatusCode
from this IG

Constraints

IdGradePath(s)DetailsRequirements
EOB-professional-nonclinician-meta-profile-versionwarningExplanationOfBenefitProfessional and Nonclinician 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-Professional-NonClinician|2.1'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefitProfessionalNonClinicianBasis Explanation of Benefit resource
EOB-prof-all-transportation-supportinginfo-linked-to-line: Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
EOB-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by value:type
.... identifier:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

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


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

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

... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee SC 0..1 BackboneElement Recipient of benefits payable
EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam SC 0..* BackboneElement Care Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy . (required)
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S 1..1 date When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing