CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.2.0 - STU 2.2 United States of America flag

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Professional NonClinician Basis

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician-Basis Version: 2.2.0
Standards status: Trial-use Active as of 2026-03-03 Computable Name: C4BBExplanationOfBenefitProfessionalNonClinicianBasis

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500. The basis profile does not have requirements for financial data.

This profile is defines the base requirements for a Professional or Non-Clinician ExplanationOfBenefit. All of the requirements are an exact subset of the original profile from earlier versions with only the financial data element requirements removed in order to address the use case of sharing Non-Financial Claims Data that enables other FHIR Implementation Guides to support communication of ExplanationOfBenefit data without financial data. These profiles are not expected to be implemented directly within the context of the consumer directed data exchange use case defined by this guide, but rather from within the context in which external guides may define (e.g. Provider Access API of PDEX).

Notes on Fields

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

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... meta SΣ 1..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
... created Σ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... payee SC 0..1 BackboneElement Recipient of benefits payable
Constraints: EOB-payee-other-type-requires-party
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... careTeam SC 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [lb_av]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [mi_i]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... insurance SΣC 1..* BackboneElement Patient insurance information
Constraints: EOB-insurance-focal
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
... item S 1..* BackboneElement Product or service provided
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
... payment S 0..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base required C4BB Related Claim Relationship Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payee.type Base required C4BB Payee Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo.category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:servicefacility.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:pickuplocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:dropofflocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payment.type Base required C4BB Payer Claim Payment Status Code Value Set 📦2.2.0 This IG

Constraints

Id Grade Path(s) Description Expression
EOB-insurance-focal error ExplanationOfBenefit.insurance EOB.insurance: at most one with focal = true select (focal = true).count() < 2
EOB-payee-other-type-requires-party error ExplanationOfBenefit.payee Base EOB: if payee type is other, payee party is required type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... type 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... careTeam C 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 Quantity Data to be provided
...... value 1..1 decimal Numerical value (with implicit precision)
...... unit 0..1 string Unit representation
Required Pattern: [lb_av]
...... system 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 Quantity Data to be provided
...... value 1..1 decimal Numerical value (with implicit precision)
...... unit 0..1 string Unit representation
Required Pattern: [mi_i]
...... system 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1 date, Period Date or dates of service or product delivery
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG

Constraints

Id Grade Path(s) Description Expression
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by value:type
.... identifier:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee SC 0..1 BackboneElement Recipient of benefits payable
Constraints: EOB-payee-other-type-requires-party
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam SC 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] S 1..1 date When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [lb_av]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code Σ 0..1 code Coded form of the unit
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [mi_i]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code Σ 0..1 code Coded form of the unit
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
Constraints: EOB-insurance-focal
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base required C4BB Related Claim Relationship Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payee.type Base required C4BB Payee Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo.category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:servicefacility.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:servicefacility.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:servicefacility.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientweight.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientweight.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:transportationdistance.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:pickuplocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:pickuplocation.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:dropofflocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:dropofflocation.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.0
ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​total.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.type Base required C4BB Payer Claim Payment Status Code Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payment.adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​formCode Base example Forms 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.type Base required NoteType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.network Base example Network Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
EOB-insurance-focal error ExplanationOfBenefit.insurance EOB.insurance: at most one with focal = true select (focal = true).count() < 2
EOB-payee-other-type-requires-party error ExplanationOfBenefit.payee Base EOB: if payee type is other, payee party is required type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 7 elements(20 nested mandatory elements)
Must-Support: 36 elements
Prohibited: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... meta SΣ 1..1 Meta Metadata about the resource
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
... created Σ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... payee SC 0..1 BackboneElement Recipient of benefits payable
Constraints: EOB-payee-other-type-requires-party
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... careTeam SC 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [lb_av]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [mi_i]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... insurance SΣC 1..* BackboneElement Patient insurance information
Constraints: EOB-insurance-focal
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
... item S 1..* BackboneElement Product or service provided
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
... payment S 0..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base required C4BB Related Claim Relationship Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payee.type Base required C4BB Payee Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo.category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:servicefacility.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:pickuplocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:dropofflocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payment.type Base required C4BB Payer Claim Payment Status Code Value Set 📦2.2.0 This IG

Constraints

Id Grade Path(s) Description Expression
EOB-insurance-focal error ExplanationOfBenefit.insurance EOB.insurance: at most one with focal = true select (focal = true).count() < 2
EOB-payee-other-type-requires-party error ExplanationOfBenefit.payee Base EOB: if payee type is other, payee party is required type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... type 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... careTeam C 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... role 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S 1..1 date When it occurred
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... category S 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Open by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 Quantity Data to be provided
...... value 1..1 decimal Numerical value (with implicit precision)
...... unit 0..1 string Unit representation
Required Pattern: [lb_av]
...... system 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 Quantity Data to be provided
...... value 1..1 decimal Numerical value (with implicit precision)
...... unit 0..1 string Unit representation
Required Pattern: [mi_i]
...... system 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
..... code 0..0 Type of information
..... timing[x] 0..0 When it occurred
..... value[x] 1..1 string Data to be provided
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1 date, Period Date or dates of service or product delivery
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... category 1..1 CodeableConcept Type of adjudication information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG

Constraints

Id Grade Path(s) Description Expression
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C 0..* C4BBExplanationOfBenefit Explanation of Benefit resource
Constraints: EOB-prof-all-transportation-supportinginfo-linked-to-line, EOB-vision-item-productorservice
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier 1..* Identifier Business Identifier for the resource
Slice: Unordered, Open by value:type
.... identifier:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... identifier:uniqueclaimid S 1..1 Identifier Unique Claim Identifier
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: uc
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string Unique Claim Identifier
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Category or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.
Required Pattern: claim
... patient SΣ 1..1 Reference(C4BB Patient) The recipient of the products and services
... billablePeriod SΣ 1..1 Period Relevant time frame for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 1..1 dateTime Response creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer SΣ 1..1 Reference(C4BB Organization) Party responsible for reimbursement
... provider SΣ 1..1 Reference(C4BB Organization | C4BB Practitioner) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship S 1..1 CodeableConcept How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S 1..1 Identifier File or case reference
... prescription 0..1 Reference(MedicationRequest | VisionPrescription) Prescription authorizing services or products
... originalPrescription 0..1 Reference(MedicationRequest) Original prescription if superceded by fulfiller
... payee SC 0..1 BackboneElement Recipient of benefits payable
Constraints: EOB-payee-other-type-requires-party
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 1..1 CodeableConcept Category of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S 0..1 Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment Referral
... facility 0..1 Reference(Location) Servicing Facility
... claim 0..1 Reference(Claim) Claim reference
... claimResponse 0..1 Reference(ClaimResponse) Claim response reference
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef 0..* string Preauthorization reference
... preAuthRefPeriod 0..* Period Preauthorization in-effect period
... careTeam SC 0..* BackboneElement Care Team members
Constraints: EOB-prof-careTeam-practitioner
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider S 1..1 Reference(C4BB Organization | C4BB Practitioner) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role S 1..1 CodeableConcept Function within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S 0..1 CodeableConcept Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (20240606) . (required)
... Slices for supportingInfo S 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:clmrecvddate S 0..1 BackboneElement Claim received date
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] S 1..1 date When it occurred
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:servicefacility S 0..1 BackboneElement Service facility
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category S 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: servicefacility
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 Reference(Resource) Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S 1..1 Reference(C4BB Organization) Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:medicalrecordnumber S 0..1 BackboneElement Medical record number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:patientaccountnumber S 0..1 BackboneElement Patient account number
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... Slices for value[x] 1..1 string Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:patientweight S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientweight
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [lb_av]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code Σ 0..1 code Coded form of the unit
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:ambulancetransportreason S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ambulancetransportreason
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 1..1 Coding Explanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: transportationdistance
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 Quantity Data to be provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... value Σ 1..1 decimal Numerical value (with implicit precision)
...... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
...... unit Σ 0..1 string Unit representation
Required Pattern: [mi_i]
...... system ΣC 0..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code Σ 0..1 code Coded form of the unit
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:roudtrippurpose S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: roudtrippurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:stretcherpurpose S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: stretcherpurpose
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:pickuplocation S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pickuplocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:dropofflocation S 0..* BackboneElement Supporting information
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: dropofflocation
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] 1..1 string Data to be provided
..... reason 0..1 Coding Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis S 1..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S 1..1 CodeableConcept Timing or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... precedence 0..1 positiveInt Precedence (primary, secondary, etc.)
... insurance SΣC 1..* BackboneElement Patient insurance information
Constraints: EOB-insurance-focal
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
.... coverage SΣ 1..1 Reference(C4BB Coverage) Insurance information
.... preAuthRef 0..* string Prior authorization reference number
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 0..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable care team members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... productOrService S 1..1 CodeableConcept Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
.... modifier S 0..* CodeableConcept Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 1..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] S 1..1 CodeableConcept Place of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... noteNumber S 0..* positiveInt Applicable note numbers
.... Slices for adjudication S 1..* BackboneElement Adjudication details
Slice: Unordered, Open by value:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:adjustmentreason S 0..* BackboneElement Reason codes used to interpret the Non-Covered Amount (92)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: adjustmentreason
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:benefitpaymentstatus S 1..1 BackboneElement Indicates the in network or out of network payment status of the claim. (142)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: benefitpaymentstatus
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
..... adjudication:allowedunits S 0..1 BackboneElement The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
........ system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version 0..1 string Version of the system - if relevant
........ code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
........ display 0..1 string Representation defined by the system
........ userSelected 0..1 boolean If this coding was chosen directly by the user
....... text 0..1 string Plain text representation of the concept
...... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monitary value
.... detail 0..* BackboneElement Additional items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Product or service provided
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Detail level adjudication details
..... subDetail 0..* BackboneElement Additional items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Product or service provided
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subDetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
.... detail 0..* BackboneElement Insurer added line items
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ExplanationOfBenefit) Added items adjudication
... Slices for adjudication S 0..* BackboneElement Header-level adjudication
Slice: Unordered, Open by value:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:billingnetworkstatus S 0..1 BackboneElement Billing provider networking status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: billingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
.... adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering provider networking status
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: renderingnetworkstatus
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... reason S 1..1 CodeableConcept Explanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monitary value
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment S 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type S 0..1 CodeableConcept Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 0..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 0..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... benefitPeriod 0..1 Period When the benefits are applicable
... benefitBalance 0..* BackboneElement Balance by Benefit Category
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category 1..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... excluded 0..1 boolean Excluded from the plan
.... name 0..1 string Short name for the benefit
.... description 0..1 string Description of the benefit or services covered
.... network 0..1 CodeableConcept In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
.... unit 0..1 CodeableConcept Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
.... term 0..1 CodeableConcept Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
.... financial 0..* BackboneElement Benefit Summary
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
..... allowed[x] 0..1 Benefits allowed
...... allowedUnsignedInt unsignedInt
...... allowedString string
...... allowedMoney Money
..... used[x] 0..1 Benefits used
...... usedUnsignedInt unsignedInt
...... usedMoney Money

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ExplanationOfBenefit.​meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​identifier:uniqueclaimid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​status Base required ExplanationOfBenefitStatus 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​type Base required C4BB Professional And Non Clinician Claim Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​use Base required Use 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​priority Base required Process Priority Codes 📦4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​related.relationship Base required C4BB Related Claim Relationship Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payee.type Base required C4BB Payee Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​careTeam.role Base required C4BB Claim Professional And Non Clinician Care Team Role Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​careTeam.qualification Base required Healthcare Provider Taxonomy . 📍20240606 VSAC v0.24
ExplanationOfBenefit.​supportingInfo.category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo.code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:clmrecvddate.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:servicefacility.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:servicefacility.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:servicefacility.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:medicalrecordnumber.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​code Base example Exception Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientaccountnumber.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientweight.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:patientweight.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:patientweight.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:ambulancetransportreason.​reason Base required C4BB Ambulance Transport Reasons Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:transportationdistance.​value[x].comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:transportationdistance.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:roudtrippurpose.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:stretcherpurpose.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:pickuplocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:pickuplocation.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​supportingInfo:dropofflocation.​category Base extensible C4BB SupportingInfo Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​supportingInfo:dropofflocation.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] Base required Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.type Base required C4BB Claim Professional And Non Clinician Diagnosis Type Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.0
ExplanationOfBenefit.​item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.productOrService Base required Procedure Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.modifier Base required Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.location[x] Base required CMS Place of Service Codes (POS) Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:adjustmentreason.​reason Base required X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:benefitpaymentstatus.​reason Base required C4BB Payer Benefit Payment Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​adjudication.category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication.reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:billingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​category Base extensible C4BB Adjudication Category Discriminator Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​adjudication:renderingnetworkstatus.​reason Base required C4BB Payer Provider Network Status Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​total.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​payment.type Base required C4BB Payer Claim Payment Status Code Value Set 📦2.2.0 This IG
ExplanationOfBenefit.​payment.adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​formCode Base example Forms 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.type Base required NoteType 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​processNote.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.network Base example Network Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit Base example Unit Type Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.term Base example Benefit Term Codes 📍4.0.1 FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type Base example Benefit Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
EOB-insurance-focal error ExplanationOfBenefit.insurance EOB.insurance: at most one with focal = true select (focal = true).count() < 2
EOB-payee-other-type-requires-party error ExplanationOfBenefit.payee Base EOB: if payee type is other, payee party is required type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()
EOB-prof-all-transportation-supportinginfo-linked-to-line error ExplanationOfBenefit Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitioner error ExplanationOfBenefit.careTeam Professional EOB: Careteam roles refer to a practitioner (role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervisor')).exists()).exists() implies provider.all(resolve() is Practitioner))
EOB-vision-item-productorservice error ExplanationOfBenefit Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision. type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
dom-2 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ExplanationOfBenefit If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ExplanationOfBenefit If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ExplanationOfBenefit A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 7 elements(20 nested mandatory elements)
Must-Support: 36 elements
Prohibited: 14 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo
  • The element 1 is sliced based on the value of ExplanationOfBenefit.supportingInfo.value[x]
  • The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication
  • The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication

 

Other representations of profile: CSV, Excel, Schematron