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.1 StructureDefinition-CARIN-BB-ExplanationOfBenefit

This profile is built upon the ExplanationOfBenefit Resource. It includes constraints that are common to the more specific EOB profiles defined in this IG. Each of the more specific EOB profiles builds upon this profile. MustSupport implementer guidance is included in this base profile (e.g. profile flags). The more specific EOB profiles therefore inherit MustSupport guidance from this base profile.

SD.1.1 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

Published on Mon Mar 16 09:12:36 UTC 2020 as a active by CARIN Alliance.

This profile builds on ExplanationOfBenefit


Summary

Mandatory: 2 elements (5 nested mandatory elements)
Must-Support: 26 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.insurance is sliced based on the value of value:focal (Closed)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefit
... id 1..1string
... identifier S1..*Identifier
... type 1..1CodeableConceptBinding: CARIN Blue Button Claim Type Value Set (extensible)
... use 1..1codeRequired Pattern: claim
... patient 1..1Reference(CARIN Blue Button Patient Profile)
... billablePeriod S0..1Period
... insurer 1..1Reference(CARIN Blue Button Organization Profile)
... provider 1..1Reference(CARIN Blue Button Organization Profile)
... related S0..*BackboneElement
.... relationship 1..1CodeableConceptBinding: CARIN Blue Button Related Claim Relationship Value Set (extensible)
... payee S0..1BackboneElement
.... type 1..1CodeableConcept
.... party 1..1Reference(CARIN Blue Button Practitioner Role Profile | CARIN Blue Button Patient Profile)
... careTeam S0..*BackboneElement
.... provider 1..1Reference(CARIN Blue Button Practitioner Role Profile)
.... responsible S0..1boolean
.... role 1..1CodeableConceptBinding: CARIN Blue Button Claim Care Team Role Value Set (extensible)
... supportingInfo S0..*BackboneElement
.... category 1..1CodeableConceptBinding: CARIN Blue Button Claim Information Category Value Set (extensible)
.... code S0..1CodeableConcept
.... timing[x] S0..1date, Period
.... value[x] S0..1boolean, string, Quantity, Attachment, Reference(Resource)
... diagnosis S0..*BackboneElement
.... diagnosis[x] 1..1CodeableConcept
.... type 1..1CodeableConceptBinding: CARIN Blue Button Diagnosis Type Value Set (extensible)
.... onAdmission S0..1CodeableConcept
... procedure S0..*BackboneElement
.... type S0..*CodeableConcept
.... date S0..1dateTime
.... procedure[x] 1..1CodeableConcept
... insurance 1..2(Slice Definition)Slice: Unordered, Closed by value:focal
.... insurance:All Slices Content/Rules for all slices
..... focal 1..1boolean
..... coverage 1..1Reference(CARIN Blue Button Coverage Profile)
.... insurance:primaryinsurance 0..1BackboneElement
..... focal 1..1booleanFixed Value: false
.... insurance:secondaryinsurance 0..1BackboneElement
..... focal 1..1booleanFixed Value: true
... item S0..*BackboneElement
.... careTeamSequence S0..*positiveInt
.... diagnosisSequence S0..*positiveInt
.... procedureSequence S0..*positiveInt
.... informationSequence S0..*positiveInt
.... category S0..1CodeableConcept
.... modifier S0..*CodeableConcept
.... serviced[x] S0..1date, Period
.... location[x] S0..1CodeableConcept, Address, Reference(Location)
.... quantity S0..1SimpleQuantity
.... net S0..1Money
... total
.... category 1..1CodeableConceptBinding: CARIN Blue Button Adjudication Amount Category Value Set (extensible)
... payment
.... adjustmentReason 0..1CodeableConceptBinding: CARIN Blue Button Adjudication Denial Reason Value Set (extensible)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*ExplanationOfBenefitExplanation 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)
... 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..*BackboneElementSupporting 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)
.... 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)
... 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
.... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
.... category SI0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier SI0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example)
.... 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..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... 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..*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: AdjudicationValueCodes (example)
..... reason I0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount I0..1MoneyMonetary amount
..... value I0..1decimalNon-monitary value
.... detail I0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence I1..1positiveIntProduct or service provided
..... revenue I0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example)
..... category I0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
..... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier I0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... programCode I0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
..... quantity I0..1SimpleQuantityCount of products or services
..... unitPrice I0..1MoneyFee, charge or cost per item
..... factor I0..1decimalPrice scaling factor
..... net I0..1MoneyTotal item cost
..... udi I0..*Reference(Device)Unique device identifier
..... noteNumber I0..*positiveIntApplicable note numbers
..... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
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
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
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
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
Added items adjudication
... adjudication I0..*Unknown reference to #ExplanationOfBenefit.item.adjudication
Header-level adjudication
... total ΣI0..*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 I0..*BackboneElementNote concerning 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
.... number I0..1positiveIntNote instance identifier
.... type I0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text I0..1stringNote explanatory text
.... language I0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... benefitPeriod I0..1PeriodWhen the benefits are applicable
... benefitBalance I0..*BackboneElementBalance by Benefit Category
.... 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..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example)
.... excluded I0..1booleanExcluded from the plan
.... name I0..1stringShort name for the benefit
.... description I0..1stringDescription of the benefit or services covered
.... network I0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example)
.... unit I0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example)
.... term I0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example)
.... financial I0..*BackboneElementBenefit Summary
..... 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..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example)
..... allowed[x] I0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] I0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format
{% include StructureDefinition-CARIN-BB-ExplanationOfBenefit-pseudo-xml.xhtml %}
{% include StructureDefinition-CARIN-BB-ExplanationOfBenefit-pseudo-json.xhtml %}

Summary

Mandatory: 2 elements (5 nested mandatory elements)
Must-Support: 26 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.insurance is sliced based on the value of value:focal (Closed)

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*ExplanationOfBenefit
... id 1..1string
... identifier S1..*Identifier
... type 1..1CodeableConceptBinding: CARIN Blue Button Claim Type Value Set (extensible)
... use 1..1codeRequired Pattern: claim
... patient 1..1Reference(CARIN Blue Button Patient Profile)
... billablePeriod S0..1Period
... insurer 1..1Reference(CARIN Blue Button Organization Profile)
... provider 1..1Reference(CARIN Blue Button Organization Profile)
... related S0..*BackboneElement
.... relationship 1..1CodeableConceptBinding: CARIN Blue Button Related Claim Relationship Value Set (extensible)
... payee S0..1BackboneElement
.... type 1..1CodeableConcept
.... party 1..1Reference(CARIN Blue Button Practitioner Role Profile | CARIN Blue Button Patient Profile)
... careTeam S0..*BackboneElement
.... provider 1..1Reference(CARIN Blue Button Practitioner Role Profile)
.... responsible S0..1boolean
.... role 1..1CodeableConceptBinding: CARIN Blue Button Claim Care Team Role Value Set (extensible)
... supportingInfo S0..*BackboneElement
.... category 1..1CodeableConceptBinding: CARIN Blue Button Claim Information Category Value Set (extensible)
.... code S0..1CodeableConcept
.... timing[x] S0..1date, Period
.... value[x] S0..1boolean, string, Quantity, Attachment, Reference(Resource)
... diagnosis S0..*BackboneElement
.... diagnosis[x] 1..1CodeableConcept
.... type 1..1CodeableConceptBinding: CARIN Blue Button Diagnosis Type Value Set (extensible)
.... onAdmission S0..1CodeableConcept
... procedure S0..*BackboneElement
.... type S0..*CodeableConcept
.... date S0..1dateTime
.... procedure[x] 1..1CodeableConcept
... insurance 1..2(Slice Definition)Slice: Unordered, Closed by value:focal
.... insurance:All Slices Content/Rules for all slices
..... focal 1..1boolean
..... coverage 1..1Reference(CARIN Blue Button Coverage Profile)
.... insurance:primaryinsurance 0..1BackboneElement
..... focal 1..1booleanFixed Value: false
.... insurance:secondaryinsurance 0..1BackboneElement
..... focal 1..1booleanFixed Value: true
... item S0..*BackboneElement
.... careTeamSequence S0..*positiveInt
.... diagnosisSequence S0..*positiveInt
.... procedureSequence S0..*positiveInt
.... informationSequence S0..*positiveInt
.... category S0..1CodeableConcept
.... modifier S0..*CodeableConcept
.... serviced[x] S0..1date, Period
.... location[x] S0..1CodeableConcept, Address, Reference(Location)
.... quantity S0..1SimpleQuantity
.... net S0..1Money
... total
.... category 1..1CodeableConceptBinding: CARIN Blue Button Adjudication Amount Category Value Set (extensible)
... payment
.... adjustmentReason 0..1CodeableConceptBinding: CARIN Blue Button Adjudication Denial Reason Value Set (extensible)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*ExplanationOfBenefitExplanation 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)
... 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..*BackboneElementSupporting 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)
.... 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)
... 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
.....