Consumer-Directed Payer Data Exchange
- Release 0.1.0

Consumer-Directed Payer Data Exchange, published by CARIN Alliance. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

SD.5 StructureDefinition-CARIN-BB-ExplanationOfBenefit-Professional-NonClinician

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

SD.5.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/carin-bb-explanationofbenefit-professional-nonclinician

Published on Fri Jul 26 00:00:00 UTC 2019 as a active by CARIN Alliance.

This profile builds on CARINBBExplanationOfBenefit


Summary

Mandatory: 4 elements (5 nested mandatory elements)
Fixed Value: 6 elements
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of value:category
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of value:category (Closed)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*CARINBBExplanationOfBenefit
... type 1..1CodeableConceptRequired Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: professional-nonclinician
... supportingInfo 0..*(Slice Definition)Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1CodeableConceptBinding: CARIN Blue Button Claim Information Category Value Set (extensible)
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElement
..... category 1..1CodeableConceptFixed Value: As shown (billingnetworkcontractingstatus)
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code 1..1CodeableConceptBinding: CARIN Blue Button Network Contracting Status Value Set (required)
.... supportingInfo:referringnetworkcontractingstatus 0..1BackboneElement
..... category 1..1CodeableConceptFixed Value: As shown (referringnetworkcontractingstatus)
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
..... code 1..1CodeableConceptBinding: CARIN Blue Button Network Contracting Status Value Set (required)
.... supportingInfo:performingnetworkcontractingstatus 0..1BackboneElement
..... category 1..1CodeableConceptFixed Value: As shown (performingnetworkcontractingstatus)
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
..... code 1..1CodeableConceptBinding: CARIN Blue Button Network Contracting Status Value Set (required)
.... supportingInfo:sitenetworkcontractingstatus 0..1BackboneElement
..... category 1..1CodeableConceptFixed Value: As shown (sitenetworkcontractingstatus)
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: sitenetworkcontractingstatus
..... code 1..1CodeableConceptBinding: CARIN Blue Button Network Contracting Status Value Set (required)
.... supportingInfo:clmrecvddate 1..1BackboneElement
..... category 1..1CodeableConceptFixed Value: As shown (clmrecvddate)
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] 1..1date
... item
.... revenue 0..0
.... category 0..1CodeableConceptBinding: CARIN Blue Button Type Of Service Value Set (required)
.... productOrService 1..1CodeableConceptBinding: CARIN Blue Button CPT/HCPCS Procedure Codes Value Set (required)
.... modifier 0..*CodeableConceptBinding: CARIN Blue Button HCPCS Modifier Codes Value Set (required)
.... location[x] 0..1CodeableConceptBinding: CARIN Blue Button Place Of Service Codes For Professional Claims Value Set (required)
.... adjudication 0..*(Slice Definition)Slice: Unordered, Closed by value:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptBinding: CARIN Blue Button Claim Adjudication Category Value Set (required)
..... adjudication:adjudicationamounttype 0..*BackboneElement
...... category 1..1CodeableConceptBinding: CARIN Blue Button Adjudication Amount Category Value Set (required)
..... adjudication:denialreason 0..1BackboneElement
...... category 1..1CodeableConceptFixed Value: As shown (payment denial reason)
....... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason 1..1CodeableConceptBinding: CARIN Blue Button Adjudication Denial Reason Value Set (required)
... adjudication:inoutnetwork 1..1BackboneElement
.... category 1..1CodeableConceptBinding: CARIN Blue Button Adjudication Benefit Payment Status Category Value Set (required)
... total 1..*BackboneElement

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*CARINBBExplanationOfBenefitExplanation of Benefit resource
... id Σ1..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SI1..*IdentifierBusiness Identifier for the resource
... status ?!ΣI1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required)
... type ΣI1..1CodeableConceptCategory or discipline
Binding: CARIN Blue Button Claim Type Value Set (extensible)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system0..1uriIdentity of the terminology system
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: professional-nonclinician
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType I0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use ΣI1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Required Pattern: claim
... patient ΣI1..1Reference(CARIN Blue Button Patient Profile)The recipient of the products and services
... billablePeriod SΣI0..1PeriodRelevant time frame for the claim
... created ΣI1..1dateTimeResponse creation date
... enterer I0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer ΣI1..1Reference(CARIN Blue Button Organization Profile)Party responsible for reimbursement
... provider ΣI1..1Reference(CARIN Blue Button Organization Profile)Party responsible for the claim
... priority I0..1CodeableConceptDesired processing urgency
Binding: http://terminology.hl7.org/CodeSystem/processpriority (example)
... fundsReserveRequested I0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example)
... fundsReserve I0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... related SI0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim I0..1Reference(Claim)Reference to the related claim
.... relationship I1..1CodeableConceptHow the reference claim is related
Binding: CARIN Blue Button Related Claim Relationship Value Set (extensible)
.... reference I0..1IdentifierFile or case reference
... prescription I0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription I0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type I1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example)
.... party I1..1Reference(CARIN Blue Button Practitioner Role Profile | CARIN Blue Button Patient Profile)Recipient reference
... referral I0..1Reference(ServiceRequest)Treatment Referral
... facility I0..1Reference(Location)Servicing Facility
... claim I0..1Reference(Claim)Claim reference
... claimResponse I0..1Reference(ClaimResponse)Claim response reference
... outcome ΣI1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition I0..1stringDisposition Message
... preAuthRef I0..*stringPreauthorization reference
... preAuthRefPeriod I0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntOrder of care team
.... provider I1..1Reference(CARIN Blue Button Practitioner Role Profile)Practitioner or organization
.... responsible SI0..1booleanIndicator of the lead practitioner
.... role I1..1CodeableConceptFunction within the team
Binding: CARIN Blue Button Claim Care Team Role Value Set (extensible)
.... qualification I0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example)
... supportingInfo SI0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:billingnetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
Fixed Value: As shown (billingnetworkcontractingstatus)
...... id0..0stringUnique id for inter-element referencing
...... extension0..0ExtensionAdditional content defined by implementations
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... version0..0stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..0stringRepresentation defined by the system
....... userSelected0..0booleanIf this coding was chosen directly by the user
...... text0..0stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: CARIN Blue Button Network Contracting Status Value Set (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:referringnetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
Fixed Value: As shown (referringnetworkcontractingstatus)
...... id0..0stringUnique id for inter-element referencing
...... extension0..0ExtensionAdditional content defined by implementations
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... version0..0stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: referringnetworkcontractingstatus
....... display0..0stringRepresentation defined by the system
....... userSelected0..0booleanIf this coding was chosen directly by the user
...... text0..0stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: CARIN Blue Button Network Contracting Status Value Set (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:performingnetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
Fixed Value: As shown (performingnetworkcontractingstatus)
...... id0..0stringUnique id for inter-element referencing
...... extension0..0ExtensionAdditional content defined by implementations
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... version0..0stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
....... display0..0stringRepresentation defined by the system
....... userSelected0..0booleanIf this coding was chosen directly by the user
...... text0..0stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: CARIN Blue Button Network Contracting Status Value Set (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:sitenetworkcontractingstatus SI0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
Fixed Value: As shown (sitenetworkcontractingstatus)
...... id0..0stringUnique id for inter-element referencing
...... extension0..0ExtensionAdditional content defined by implementations
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... version0..0stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: sitenetworkcontractingstatus
....... display0..0stringRepresentation defined by the system
....... userSelected0..0booleanIf this coding was chosen directly by the user
...... text0..0stringPlain text representation of the concept
..... code SI1..1CodeableConceptType of information
Binding: CARIN Blue Button Network Contracting Status Value Set (required)
..... timing[x] SI0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
.... supportingInfo:clmrecvddate SI1..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntInformation instance identifier
..... category I1..1CodeableConceptClassification of the supplied information
Binding: CARIN Blue Button Claim Information Category Value Set (extensible)
Fixed Value: As shown (clmrecvddate)
...... id0..0stringUnique id for inter-element referencing
...... extension0..0ExtensionAdditional content defined by implementations
...... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory
....... version0..0stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..0stringRepresentation defined by the system
....... userSelected0..0booleanIf this coding was chosen directly by the user
...... text0..0stringPlain text representation of the concept
..... code SI0..1CodeableConceptType of information
Binding: ExceptionCodes (example)
..... timing[x] SI1..1dateWhen it occurred
..... value[x] SI0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason I0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example)
... diagnosis SI0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] I1..1CodeableConceptNature of illness or problem
Binding: ICD-10Codes (example)
.... type I1..1CodeableConceptTiming or nature of the diagnosis
Binding: CARIN Blue Button Diagnosis Type Value Set (extensible)
.... onAdmission SI0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example)
.... packageCode I0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... procedure SI0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntProcedure instance identifier
.... type SI0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example)
.... date SI0..1dateTimeWhen the procedure was performed
.... procedure[x] I1..1CodeableConceptSpecific clinical procedure
Binding: ICD-10ProcedureCodes (example)
.... udi I0..*Reference(Device)Unique device identifier
... precedence I0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance ΣI1..2(Slice Definition)Patient insurance information
Slice: Unordered, Closed by value:focal
.... insurance:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... focal ΣI1..1booleanCoverage to be used for adjudication
..... coverage ΣI1..1Reference(CARIN Blue Button Coverage Profile)Insurance information
..... preAuthRef I0..*stringPrior authorization reference number
.... insurance:primaryinsurance ΣI0..1BackboneElementPatient insurance information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... focal ΣI1..1booleanCoverage to be used for adjudication
Fixed Value: false
..... coverage ΣI1..1Reference(Coverage)Insurance information
..... preAuthRef I0..*stringPrior authorization reference number
.... insurance:secondaryinsurance ΣI0..1BackboneElementPatient insurance information
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... focal ΣI1..1booleanCoverage to be used for adjudication
Fixed Value: true
..... coverage ΣI1..1Reference(Coverage)Insurance information
..... preAuthRef I0..*stringPrior authorization reference number
... accident I0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date I0..1dateWhen the incident occurred
.... type I0..1CodeableConceptThe nature of the accident
Binding: V3 Value SetActIncidentCode (extensible)
.... location[x] I0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item SI0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence I1..1positiveIntItem instance identifier
.... careTeamSequence SI0..*positiveIntApplicable care team members
.... diagnosisSequence SI0..*positiveIntApplicable diagnoses
.... procedureSequence SI0..*positiveIntApplicable procedures
.... informationSequence SI0..*positiveIntApplicable exception and supporting information
.... category SI0..1CodeableConceptBenefit classification
Binding: CARIN Blue Button Type Of Service Value Set (required)
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: CARIN Blue Button CPT/HCPCS Procedure Codes Value Set (required)
.... modifier SI0..*CodeableConceptProduct or service billing modifiers
Binding: CARIN Blue Button HCPCS Modifier Codes Value Set (required)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] SI0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] SI0..1CodeableConceptPlace of service or where product was supplied
Binding: CARIN Blue Button Place Of Service Codes For Professional Claims Value Set (required)
.... quantity SI0..1SimpleQuantityCount of products or services
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net SI0..1MoneyTotal item cost
.... udi I0..*Reference(Device)Unique device identifier
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... encounter I0..*Reference(Encounter)Encounters related to this billed item
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication I0..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by value:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category I1..1CodeableConceptType of adjudication information
Binding: CARIN Blue Button Claim Adjudication Category Value Set (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype I0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category I1..1CodeableConceptType of adjudication information
Binding: CARIN Blue Button Adjudication Amount Category Value Set (required)
...... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
..... adjudication:denialreason I0..1BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category I1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
Fixed Value: As shown (payment denial reason)
....... id0..0stringUnique id for inter-element referencing
....... extension0..0ExtensionAdditional content defined by implementations
....... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..0stringUnique id for inter-element referencing
........ extension0..0ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory
........ version0..0stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..0stringRepresentation defined by the system
........ userSelected0..0booleanIf this coding was chosen directly by the user
....... text0..0stringPlain text representation of the concept
...... reason I1..1CodeableConceptExplanation of adjudication outcome
Binding: CARIN Blue Button Adjudication Denial Reason Value Set (required)
...... amount I0..1MoneyMonetary amount
...... value I0..1decimalNon-monitary value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntProduct or service provided
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason
Detail level adjudication details
..... subDetail I0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence I1..1positiveIntProduct or service provided
...... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
...... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... udi I0..*Reference(Device)Unique device identifier
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason
Subdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence I0..*positiveIntItem sequence number
.... detailSequence I0..*positiveIntDetail sequence number
.... subDetailSequence I0..*positiveIntSubdetail sequence number
.... provider I0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] I0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] I0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity I0..1SimpleQuantityCount of products or services
.... unitPrice I0..1MoneyFee, charge or cost per item
.... factor I0..1decimalPrice scaling factor
.... net I0..1MoneyTotal item cost
.... bodySite I0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite I0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber I0..*positiveIntApplicable note numbers
.... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason
Added items adjudication
.... detail I0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason
Added items adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity I0..1SimpleQuantityCount of products or services
...... unitPrice I0..1MoneyFee, charge or cost per item
...... factor I0..1decimalPrice scaling factor
...... net I0..1MoneyTotal item cost
...... noteNumber I0..*positiveIntApplicable note numbers
...... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason
Added items adjudication
... adjudication:inoutnetwork I1..1BackboneElementHeader-level adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category I1..1CodeableConceptType of adjudication information
Binding: CARIN Blue Button Adjudication Benefit Payment Status Category Value Set (required)
.... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
.... amount I0..1MoneyMonetary amount
.... value I0..1decimalNon-monitary value
... total ΣI1..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category ΣI1..1CodeableConceptType of adjudication information
Binding: CARIN Blue Button Adjudication Amount Category Value Set (extensible)
.... amount ΣI1..1MoneyFinancial total for the category
... payment I0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type I0..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example)
.... adjustment I0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason I0..1CodeableConceptExplanation for the variance
Binding: CARIN Blue Button Adjudication Denial Reason Value Set (extensible)
.... date I0..1dateExpected date of payment
.... amount I0..1MoneyPayable amount after adjustment
.... identifier I0..1IdentifierBusiness identifier for the payment
... formCode I0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form I0..1AttachmentPrinted reference or actual form
... processNote