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: C4BBExplanationOfBenefit

Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four non-abstract EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician

The official URL for this profile is:

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

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitThis is an abstract profile
Explanation of Benefit resource
... meta
.... lastUpdated S1..1instantWhen the resource version last changed
.... profile S1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type S1..1CodeableConceptDescription of identifier
... type S1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
... patient S1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod S0..1PeriodRelevant time frame for the claim
... insurer S1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... related S0..*BackboneElementPrior or corollary claims
.... relationship S1..1CodeableConceptHow the reference claim is related
... payee S0..1BackboneElementRecipient of benefits payable
.... type S1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (required)
.... party S1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... careTeam S0..*BackboneElementCare Team members
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible S0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
... supportingInfo S0..*BackboneElementSupporting information
.... code S0..1CodeableConceptType of information
.... timing[x] S0..1date, PeriodWhen it occurred
.... value[x] S0..1boolean, string, Quantity, Attachment, Reference(Resource)Data to be provided
... procedure S0..*BackboneElementClinical procedures performed
.... type S0..*CodeableConceptCategory of Procedure
.... date S0..1dateTimeWhen the procedure was performed
... insurance SI1..*BackboneElementPatient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... focal S1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(C4BB Coverage)Insurance information
... item S0..*BackboneElementProduct or service provided
.... noteNumber S0..*positiveIntReferences number of the associated processNote
.... adjudication S0..*BackboneElementAdjudication details
..... category S1..1CodeableConceptType of adjudication information
... adjudication S0..*Header-level adjudication
... payment S0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
... processNote S0..*BackboneElementLine member payment denial explanation

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitThis is an abstract profile
Explanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type SΣ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee S0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (required)
.... party S1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam S0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible S0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo S0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example)
.... code S0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
.... timing[x] S0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] S0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example)
.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure S0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type S0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SΣI1..*BackboneElementPatient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣ1..1booleanCoverage to be used for adjudication
.... coverage SΣ1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber S0..*positiveIntReferences number of the associated processNote
.... adjudication S0..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudicationAdded items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudicationAdded items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudicationAdded items adjudication
... adjudication S0..*See adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
.... amount Σ1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example)
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementLine member payment denial explanation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example)
.... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example)
.... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example)
.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example)
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitThis is an abstract profile
Explanation of Benefit resource
... meta Σ0..1MetaMetadata about the resource
.... lastUpdated Σ1..1instantWhen the resource version last changed
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... insurer Σ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider Σ1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... related 0..*BackboneElementPrior or corollary claims
.... relationship 1..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example)
... payee 0..1BackboneElementRecipient of benefits payable
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (required)
.... party 1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... careTeam 0..*BackboneElementCare Team members
.... provider 1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 1..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example)
... supportingInfo 0..*BackboneElementSupporting information
.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
... procedure 0..*BackboneElementClinical procedures performed
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date 0..1dateTimeWhen the procedure was performed
... insurance ΣI1..*BackboneElementPatient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(C4BB Coverage)Insurance information
... item 0..*BackboneElementProduct or service provided
.... noteNumber 0..*positiveIntReferences number of the associated processNote
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
... adjudication 0..*See adjudicationHeader-level adjudication
... payment 0..1BackboneElementPayment Details
... processNote 0..*BackboneElementLine member payment denial explanation

doco Documentation for this format

Differential View

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitThis is an abstract profile
Explanation of Benefit resource
... meta
.... lastUpdated S1..1instantWhen the resource version last changed
.... profile S1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type S1..1CodeableConceptDescription of identifier
... type S1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
... patient S1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod S0..1PeriodRelevant time frame for the claim
... insurer S1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... related S0..*BackboneElementPrior or corollary claims
.... relationship S1..1CodeableConceptHow the reference claim is related
... payee S0..1BackboneElementRecipient of benefits payable
.... type S1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (required)
.... party S1..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... careTeam S0..*BackboneElementCare Team members
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible S0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
... supportingInfo S0..*BackboneElementSupporting information
.... code S0..1CodeableConceptType of information
.... timing[x] S0..1date, PeriodWhen it occurred
.... value[x] S0..1boolean, string, Quantity, Attachment, Reference(Resource)Data to be provided
... procedure S0..*BackboneElementClinical procedures performed
.... type S0..*CodeableConceptCategory of Procedure
.... date S0..1dateTimeWhen the procedure was performed
... insurance SI1..*BackboneElementPatient insurance information
EOB-insurance-focal: EOB.insurance: at most one with focal = true
.... focal S1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(C4BB Coverage)Insurance information
... item S0..*BackboneElementProduct or service provided
.... noteNumber S0..*positiveIntReferences number of the associated processNote
.... adjudication S0..*BackboneElementAdjudication details
..... category S1..1CodeableConceptType of adjudication information
... adjudication S0..*Header-level adjudication
... payment S0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
... processNote S0..*BackboneElementLine member payment denial explanation

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefitThis is an abstract profile
Explanation of Benefit resource
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type SΣ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services