Da Vinci Payer Data Exchange
2.1.0 - STU2 United States of America flag

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

Resource Profile: PdexPriorAuthorization - Detailed Descriptions

Page standards status: Trial-use

Definitions for the pdex-priorauthorization resource profile.

Guidance on how to interpret the contents of this table can be found here

0. ExplanationOfBenefit
Invariantsadjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ((adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()))
2. ExplanationOfBenefit.meta
4. ExplanationOfBenefit.meta.profile
Control1..?
SlicingThis element introduces a set of slices on ExplanationOfBenefit.meta.profile. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 6. ExplanationOfBenefit.meta.profile:supportedProfile
    Slice NamesupportedProfile
    Control1..1
    Pattern Valuehttp://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
    8. ExplanationOfBenefit.extension
    SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 10. ExplanationOfBenefit.extension:levelOfServiceType
      Slice NamelevelOfServiceType
      ShortA code specifying the level of service being requested (UM06)
      Control0..1
      TypeExtension(LevelOfServiceCode) (Extension Type: CodeableConcept)
      Must Supporttrue
      12. ExplanationOfBenefit.status
      Must Supporttrue
      14. ExplanationOfBenefit.type
      Must Supporttrue
      16. ExplanationOfBenefit.use
      Must Supporttrue
      Pattern Valuepreauthorization
      18. ExplanationOfBenefit.patient
      TypeReference(US Core Patient Profile)
      Must Supporttrue
      20. ExplanationOfBenefit.enterer
      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile)
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      22. ExplanationOfBenefit.insurer
      TypeReference(US Core Organization Profile)
      Must Supporttrue
      24. ExplanationOfBenefit.provider
      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      26. ExplanationOfBenefit.priority
      BindingThe codes SHALL be taken from ProcessPriorityCodes
      (required to http://hl7.org/fhir/ValueSet/process-priority)
      28. ExplanationOfBenefit.facility
      TypeReference(US Core Location Profile)
      Must Supporttrue
      30. ExplanationOfBenefit.preAuthRefPeriod
      Comments

      Prior Authorization in-effect period

      Control0..1
      Must Supporttrue
      32. ExplanationOfBenefit.careTeam
      34. ExplanationOfBenefit.careTeam.provider
      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      36. ExplanationOfBenefit.insurance
      38. ExplanationOfBenefit.insurance.coverage
      TypeReference(HRex Coverage Profile)
      40. ExplanationOfBenefit.item
      42. ExplanationOfBenefit.item.extension
      SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 44. ExplanationOfBenefit.item.extension:itemTraceNumber
        Slice NameitemTraceNumber
        ShortUniquely identifies this claim item. (2000F-TRN)
        Control0..*
        TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
        Must Supporttrue
        46. ExplanationOfBenefit.item.extension:preAuthIssueDate
        Slice NamepreAuthIssueDate
        ShortThe date when this item's preauthorization was issued.
        Control0..1
        TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
        Must Supporttrue
        48. ExplanationOfBenefit.item.extension:preAuthPeriod
        Slice NamepreAuthPeriod
        ShortThe date/period when this item's preauthorization is valid.
        Control0..1
        TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
        Must Supporttrue
        50. ExplanationOfBenefit.item.extension:previousAuthorizationNumber
        Slice NamepreviousAuthorizationNumber
        ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
        Control0..1
        TypeExtension(AuthorizationNumber) (Extension Type: string)
        Must Supporttrue
        52. ExplanationOfBenefit.item.extension:administrationReferenceNumber
        Slice NameadministrationReferenceNumber
        ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
        Control0..1
        TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
        Must Supporttrue
        54. ExplanationOfBenefit.item.extension:authorizedItemDetail
        Slice NameauthorizedItemDetail
        ShortThe details of what has been authorized for this item if different from what was requested.
        Control0..1
        TypeExtension(ItemAuthorizedDetail) (Complex Extension)
        Must Supporttrue
        56. ExplanationOfBenefit.item.extension:authorizedProvider
        Slice NameauthorizedProvider
        ShortThe specific provider who has been authorized to provide this item.
        Control0..*
        TypeExtension(ItemAuthorizedProvider) (Complex Extension)
        Must Supporttrue
        58. ExplanationOfBenefit.item.category
        BindingThe codes SHALL be taken from Prior Authorization Service Type Codes (X12)
        (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes)

        Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

        Must Supporttrue
        60. ExplanationOfBenefit.item.productOrService
        BindingThe codes SHALL be taken from Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS
        (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS)
        62. ExplanationOfBenefit.item.encounter
        TypeReference(US Core Encounter Profile)
        64. ExplanationOfBenefit.item.adjudication
        SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices areUnordered and Closed, and can be differentiated using the following discriminators:
        • pattern @ category
        • 66. ExplanationOfBenefit.item.adjudication.extension
          SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 68. ExplanationOfBenefit.item.adjudication.extension:reviewAction
            Slice NamereviewAction
            ShortThe details of the review action that is necessary for the authorization at the line level.
            Control0..1
            TypeExtension(ReviewAction) (Complex Extension)
            Must Supporttrue
            70. ExplanationOfBenefit.item.adjudication.extension:adjudicationActionDate
            Slice NameadjudicationActionDate
            ShortThe date/time when an Adjudication Action occured.
            Control0..1
            TypeExtension(When Adjudicated) (Extension Type: dateTime)
            Must Supporttrue
            72. ExplanationOfBenefit.item.adjudication.category
            BindingThe codes SHALL be taken from PDex Adjudication Category Discriminator
            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator)
            74. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
            Slice Nameadjudicationamounttype
            Control0..*
            Must Supporttrue
            76. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
            BindingThe codes SHALL be taken from PDex Adjudication
            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication)
            78. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
            Control1..?
            Must Supporttrue
            80. ExplanationOfBenefit.item.adjudication:allowedunits
            Slice Nameallowedunits
            Control0..1
            Must Supporttrue
            82. ExplanationOfBenefit.item.adjudication:allowedunits.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                "code" : "allowedunits"
              }]
            }
            84. ExplanationOfBenefit.item.adjudication:allowedunits.value
            Control1..?
            Must Supporttrue
            86. ExplanationOfBenefit.item.adjudication:denialreason
            Slice Namedenialreason
            Control0..*
            Must Supporttrue
            88. ExplanationOfBenefit.item.adjudication:denialreason.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                "code" : "denialreason"
              }]
            }
            90. ExplanationOfBenefit.item.adjudication:denialreason.reason
            Control1..?
            BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes
            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes)
            Must Supporttrue
            92. ExplanationOfBenefit.item.adjudication:consumedunits
            Slice Nameconsumedunits
            Control0..1
            94. ExplanationOfBenefit.item.adjudication:consumedunits.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                "code" : "consumedunits"
              }]
            }
            96. ExplanationOfBenefit.item.adjudication:consumedunits.value
            Control1..?
            98. ExplanationOfBenefit.addItem
            100. ExplanationOfBenefit.addItem.provider
            TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
            102. ExplanationOfBenefit.adjudication
            TypeBackboneElement
            Must Supporttrue
            SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices areUnordered and Closed, and can be differentiated using the following discriminators:
            • pattern @ category
            • 104. ExplanationOfBenefit.adjudication.extension
              SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 106. ExplanationOfBenefit.adjudication.extension:reviewAction
                Slice NamereviewAction
                ShortThe details of the review action that is necessary for the authorization for the entire request.
                Control0..1
                TypeExtension(ReviewAction) (Complex Extension)
                Must Supporttrue
                108. ExplanationOfBenefit.adjudication.extension:adjudicationActionDate
                Slice NameadjudicationActionDate
                ShortThe date/time when an Adjudication Action occured.
                Control0..1
                TypeExtension(When Adjudicated) (Extension Type: dateTime)
                Must Supporttrue
                110. ExplanationOfBenefit.adjudication.category
                BindingThe codes SHALL be taken from PDex Adjudication Category Discriminator
                (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator)
                Must Supporttrue
                112. ExplanationOfBenefit.adjudication:adjudicationamounttype
                Slice Nameadjudicationamounttype
                Control0..*
                Must Supporttrue
                114. ExplanationOfBenefit.adjudication:adjudicationamounttype.category
                BindingThe codes SHALL be taken from PDex Adjudication
                (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication)
                116. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
                Control1..?
                118. ExplanationOfBenefit.adjudication:denialreason
                Slice Namedenialreason
                Control0..*
                Must Supporttrue
                120. ExplanationOfBenefit.total
                122. ExplanationOfBenefit.total.extension
                SlicingThis element introduces a set of slices on ExplanationOfBenefit.total.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 124. ExplanationOfBenefit.total.extension:priorauth-utilization
                  Slice Namepriorauth-utilization
                  Control0..1
                  TypeExtension(An attribute to express the amount of a service or item that has been utilized) (Extension Type: Choice of: Quantity, Ratio)
                  Must Supporttrue
                  126. ExplanationOfBenefit.total.category
                  ShortPrior Authorization utilization codes
                  BindingUnless not suitable, these codes SHALL be taken from Prior Authorization value categories
                  (extensible to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts)
                  Must Supporttrue

                  Guidance on how to interpret the contents of this table can be found here

                  0. ExplanationOfBenefit
                  Definition

                  This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

                  ShortExplanation of Benefit resource
                  Control0..*
                  Is Modifierfalse
                  Summaryfalse
                  Alternate NamesEOB
                  Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
                  dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
                  dom-6: A resource should have narrative for robust management (text.`div`.exists())
                  adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ((adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()))
                  2. ExplanationOfBenefit.implicitRules
                  Definition

                  A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

                  ShortA set of rules under which this content was created
                  Comments

                  Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

                  Control0..1
                  Typeuri
                  Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  4. ExplanationOfBenefit.extension
                  Definition

                  An Extension


                  May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortExtensionAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                  • value @ url
                  • 6. ExplanationOfBenefit.extension:levelOfServiceType
                    Slice NamelevelOfServiceType
                    Definition

                    A code specifying the level of service being requested (UM06)

                    ShortA code specifying the level of service being requested (UM06)
                    Control0..1
                    This element is affected by the following invariants: ele-1
                    TypeExtension(LevelOfServiceCode) (Extension Type: CodeableConcept)
                    Is Modifierfalse
                    Must Supporttrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    8. ExplanationOfBenefit.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
                    Summaryfalse
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    10. ExplanationOfBenefit.status
                    Definition

                    The status of the resource instance.

                    Shortactive | cancelled | draft | entered-in-error
                    Comments

                    This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

                    Control1..1
                    BindingThe codes SHALL be taken from ExplanationOfBenefitStatushttp://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
                    (required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1)

                    A code specifying the state of the resource instance.

                    Typecode
                    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    12. ExplanationOfBenefit.type
                    Definition

                    The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

                    ShortCategory or discipline
                    Comments

                    The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

                    Control1..1
                    BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
                    (extensible to http://hl7.org/fhir/ValueSet/claim-type)

                    The type or discipline-style of the claim.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    Claim type determine the general sets of business rules applied for information requirements and adjudication.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    14. ExplanationOfBenefit.use
                    Definition

                    A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

                    Shortclaim | preauthorization | predetermination
                    Control1..1
                    BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
                    (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

                    Complete, proposed, exploratory, other.

                    Typecode
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    This element is required to understand the nature of the request for adjudication.

                    Pattern Valuepreauthorization
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    16. ExplanationOfBenefit.patient
                    Definition

                    The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

                    ShortThe recipient of the products and services
                    Control1..1
                    TypeReference(US Core Patient Profile, Patient)
                    Is Modifierfalse
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    18. ExplanationOfBenefit.created
                    Definition

                    The date this resource was created.

                    ShortResponse creation date
                    Comments

                    This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

                    Control1..1
                    TypedateTime
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summarytrue
                    Requirements

                    Need to record a timestamp for use by both the recipient and the issuer.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    20. ExplanationOfBenefit.enterer
                    Definition

                    Individual who created the claim, predetermination or preauthorization.

                    ShortAuthor of the claim
                    Control0..1
                    TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, Practitioner, PractitionerRole)
                    Is Modifierfalse
                    Must Supporttrue
                    Must Support TypesNo must-support rules about the choice of types/profiles
                    Summaryfalse
                    Requirements

                    Some jurisdictions require the contact information for personnel completing claims.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    22. ExplanationOfBenefit.insurer
                    Definition

                    The party responsible for authorization, adjudication and reimbursement.

                    ShortParty responsible for reimbursement
                    Control1..1
                    TypeReference(US Core Organization Profile, Organization)
                    Is Modifierfalse
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    24. ExplanationOfBenefit.provider
                    Definition

                    The provider which is responsible for the claim, predetermination or preauthorization.

                    ShortParty responsible for the claim
                    Comments

                    Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

                    Control1..1
                    TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile, Practitioner, PractitionerRole, Organization)
                    Is Modifierfalse
                    Must Supporttrue
                    Must Support TypesNo must-support rules about the choice of types/profiles
                    Summarytrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    26. ExplanationOfBenefit.priority
                    Definition

                    The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

                    ShortDesired processing urgency
                    Comments

                    If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

                    Control0..1
                    BindingThe codes SHALL be taken from For example codes, see ProcessPriorityCodeshttp://terminology.hl7.org/CodeSystem/processpriority
                    (required to http://hl7.org/fhir/ValueSet/process-priority)
                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    28. ExplanationOfBenefit.facility
                    Definition

                    Facility where the services were provided.

                    ShortServicing Facility
                    Control0..1
                    TypeReference(US Core Location Profile, Location)
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Requirements

                    Insurance adjudication can be dependant on where services were delivered.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    30. ExplanationOfBenefit.outcome
                    Definition

                    The outcome of the claim, predetermination, or preauthorization processing.

                    Shortqueued | complete | error | partial
                    Comments

                    The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

                    Control1..1
                    BindingThe codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
                    (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

                    The result of the claim processing.

                    Typecode
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summarytrue
                    Requirements

                    To advise the requestor of an overall processing outcome.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    32. ExplanationOfBenefit.preAuthRefPeriod
                    Definition

                    The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

                    ShortPreauthorization in-effect period
                    Comments

                    Prior Authorization in-effect period


                    This value is only present on preauthorization adjudications.

                    Control0..1*
                    TypePeriod
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Requirements

                    On subsequent claims, the insurer may require the provider to quote this value.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    34. ExplanationOfBenefit.careTeam
                    Definition

                    The members of the team who provided the products and services.

                    ShortCare Team members
                    Control0..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Common to identify the responsible and supporting practitioners.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    36. ExplanationOfBenefit.careTeam.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    38. ExplanationOfBenefit.careTeam.sequence
                    Definition

                    A number to uniquely identify care team entries.

                    ShortOrder of care team
                    Control1..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    40. ExplanationOfBenefit.careTeam.provider
                    Definition

                    Member of the team who provided the product or service.

                    ShortPractitioner or organization
                    Control1..1
                    TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile, Practitioner, PractitionerRole, Organization)
                    Is Modifierfalse
                    Must Supporttrue
                    Must Support TypesNo must-support rules about the choice of types/profiles
                    Summaryfalse
                    Requirements

                    Often a regulatory requirement to specify the responsible provider.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    42. ExplanationOfBenefit.insurance
                    Definition

                    Financial instruments for reimbursement for the health care products and services specified on the claim.

                    ShortPatient insurance information
                    Comments

                    All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

                    Control1..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summarytrue
                    Requirements

                    At least one insurer is required for a claim to be a claim.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    44. ExplanationOfBenefit.insurance.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    46. ExplanationOfBenefit.insurance.focal
                    Definition

                    A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

                    ShortCoverage to be used for adjudication
                    Comments

                    A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

                    Control1..1
                    Typeboolean
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summarytrue
                    Requirements

                    To identify which coverage in the list is being used to adjudicate this claim.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    48. ExplanationOfBenefit.insurance.coverage
                    Definition

                    Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

                    ShortInsurance information
                    Control1..1
                    TypeReference(HRex Coverage Profile, Coverage)
                    Is Modifierfalse
                    Summarytrue
                    Requirements

                    Required to allow the adjudicator to locate the correct policy and history within their information system.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    50. ExplanationOfBenefit.item
                    Definition

                    A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

                    ShortProduct or service provided
                    Control0..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    The items to be processed for adjudication.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    52. ExplanationOfBenefit.item.extension
                    Definition

                    An Extension


                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortExtensionAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                    • value @ url
                    • 54. ExplanationOfBenefit.item.extension:itemTraceNumber
                      Slice NameitemTraceNumber
                      Definition

                      Uniquely identifies this claim item. (2000F-TRN)

                      ShortUniquely identifies this claim item. (2000F-TRN)
                      Control0..*
                      This element is affected by the following invariants: ele-1
                      TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      56. ExplanationOfBenefit.item.extension:preAuthIssueDate
                      Slice NamepreAuthIssueDate
                      Definition

                      The date when this item's preauthorization was issued.

                      ShortThe date when this item's preauthorization was issued.
                      Control0..1
                      This element is affected by the following invariants: ele-1
                      TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      58. ExplanationOfBenefit.item.extension:preAuthPeriod
                      Slice NamepreAuthPeriod
                      Definition

                      The date/period when this item's preauthorization is valid.

                      ShortThe date/period when this item's preauthorization is valid.
                      Control0..1
                      This element is affected by the following invariants: ele-1
                      TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      60. ExplanationOfBenefit.item.extension:previousAuthorizationNumber
                      Slice NamepreviousAuthorizationNumber
                      Definition

                      A string assigned by the UMO to an authorized review outcome associated with this service item.

                      ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
                      Control0..1
                      This element is affected by the following invariants: ele-1
                      TypeExtension(AuthorizationNumber) (Extension Type: string)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      62. ExplanationOfBenefit.item.extension:administrationReferenceNumber
                      Slice NameadministrationReferenceNumber
                      Definition

                      A string assigned by the UMO to the original disallowed review outcome associated with this service item.

                      ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
                      Control0..1
                      This element is affected by the following invariants: ele-1
                      TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      64. ExplanationOfBenefit.item.extension:authorizedItemDetail
                      Slice NameauthorizedItemDetail
                      Definition

                      The details of what has been authorized for this item if different from what was requested.

                      ShortThe details of what has been authorized for this item if different from what was requested.
                      Control0..1
                      This element is affected by the following invariants: ele-1
                      TypeExtension(ItemAuthorizedDetail) (Complex Extension)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      66. ExplanationOfBenefit.item.extension:authorizedProvider
                      Slice NameauthorizedProvider
                      Definition

                      The specific provider who has been authorized to provide this item.

                      ShortThe specific provider who has been authorized to provide this item.
                      Control0..*
                      This element is affected by the following invariants: ele-1
                      TypeExtension(ItemAuthorizedProvider) (Complex Extension)
                      Is Modifierfalse
                      Must Supporttrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      68. ExplanationOfBenefit.item.modifierExtension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                      ShortExtensions that cannot be ignored even if unrecognized
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                      Summarytrue
                      Requirements

                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                      Alternate Namesextensions, user content, modifiers
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      70. ExplanationOfBenefit.item.sequence
                      Definition

                      A number to uniquely identify item entries.

                      ShortItem instance identifier
                      Control1..1
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      72. ExplanationOfBenefit.item.category
                      Definition

                      Code to identify the general type of benefits under which products and services are provided.

                      ShortBenefit classification
                      Comments

                      Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                      Control0..1
                      BindingThe codes SHALL be taken from For example codes, see Prior Authorization Service Type Codes (X12)http://hl7.org/fhir/ValueSet/ex-benefitcategory
                      (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes)

                      Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


                      Benefit categories such as: oral, medical, vision, oral-basic etc.

                      TypeCodeableConcept
                      Is Modifierfalse
                      Must Supporttrue
                      Summaryfalse
                      Requirements

                      Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      74. ExplanationOfBenefit.item.productOrService
                      Definition

                      When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                      ShortBilling, service, product, or drug code
                      Comments

                      If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                      Control1..1
                      BindingThe codes SHALL be taken from For example codes, see Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPShttp://hl7.org/fhir/ValueSet/service-uscls
                      (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS)
                      TypeCodeableConcept
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Necessary to state what was provided or done.

                      Alternate NamesDrug Code, Bill Code, Service Code
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      76. ExplanationOfBenefit.item.encounter
                      Definition

                      A billed item may include goods or services provided in multiple encounters.

                      ShortEncounters related to this billed item
                      Control0..*
                      TypeReference(US Core Encounter Profile, Encounter)
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Used in some jurisdictions to link clinical events to claim items.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      78. ExplanationOfBenefit.item.adjudication
                      Definition

                      If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                      ShortAdjudication details
                      Control0..*
                      TypeBackboneElement
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices areUnordered and Closed, and can be differentiated using the following discriminators:
                      • pattern @ category
                      • 80. ExplanationOfBenefit.item.adjudication.extension
                        Definition

                        An Extension


                        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                        ShortExtensionAdditional content defined by implementations
                        Comments

                        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                        Control0..*
                        TypeExtension
                        Is Modifierfalse
                        Summaryfalse
                        Alternate Namesextensions, user content
                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                        • value @ url
                        • 82. ExplanationOfBenefit.item.adjudication.extension:reviewAction
                          Slice NamereviewAction
                          Definition

                          The details of the review action that is necessary for the authorization.

                          ShortThe details of the review action that is necessary for the authorization at the line level.
                          Control0..1
                          This element is affected by the following invariants: ele-1
                          TypeExtension(ReviewAction) (Complex Extension)
                          Is Modifierfalse
                          Must Supporttrue
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          84. ExplanationOfBenefit.item.adjudication.extension:adjudicationActionDate
                          Slice NameadjudicationActionDate
                          Definition

                          Date and Time when Adjudication Action took place. NOTE: that this extension may be replaced by an inter-version extension after R6 version of the EOB implements this DataTime element.

                          ShortThe date/time when an Adjudication Action occured.
                          Control0..1
                          This element is affected by the following invariants: ele-1
                          TypeExtension(When Adjudicated) (Extension Type: dateTime)
                          Is Modifierfalse
                          Must Supporttrue
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          86. ExplanationOfBenefit.item.adjudication.modifierExtension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                          Summarytrue
                          Requirements

                          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                          Alternate Namesextensions, user content, modifiers
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          88. ExplanationOfBenefit.item.adjudication.category
                          Definition

                          A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                          ShortType of adjudication information
                          Comments

                          For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                          Control1..1
                          BindingThe codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminatorhttp://hl7.org/fhir/ValueSet/adjudication
                          (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator)
                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Needed to enable understanding of the context of the other information in the adjudication.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          90. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
                          Slice Nameadjudicationamounttype
                          Definition

                          If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                          ShortAdjudication details
                          Control0..*
                          TypeBackboneElement
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          92. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.modifierExtension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                          Summarytrue
                          Requirements

                          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                          Alternate Namesextensions, user content, modifiers
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          94. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
                          Definition

                          A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                          ShortType of adjudication information
                          Comments

                          For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                          Control1..1
                          BindingThe codes SHALL be taken from For example codes, see PDex Adjudicationhttp://hl7.org/fhir/ValueSet/adjudication
                          (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication)
                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Needed to enable understanding of the context of the other information in the adjudication.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          96. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
                          Definition

                          Monetary amount associated with the category.

                          ShortMonetary amount
                          Comments

                          For example, amount submitted, eligible amount, co-payment, and benefit payable.

                          Control10..1
                          TypeMoney
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          Most adjuciation categories convey a monetary amount.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          98. ExplanationOfBenefit.item.adjudication:allowedunits
                          Slice Nameallowedunits
                          Definition

                          If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                          ShortAdjudication details
                          Control0..1*
                          TypeBackboneElement
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          100. ExplanationOfBenefit.item.adjudication:allowedunits.modifierExtension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                          Summarytrue
                          Requirements

                          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                          Alternate Namesextensions, user content, modifiers
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          102. ExplanationOfBenefit.item.adjudication:allowedunits.category
                          Definition

                          A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                          ShortType of adjudication information
                          Comments

                          For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                          Control1..1
                          BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
                          (example to http://hl7.org/fhir/ValueSet/adjudication)

                          The adjudication codes.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Needed to enable understanding of the context of the other information in the adjudication.

                          Pattern Value{
                            "coding" : [{
                              "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                              "code" : "allowedunits"
                            }]
                          }
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          104. ExplanationOfBenefit.item.adjudication:allowedunits.value
                          Definition

                          A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                          ShortNon-monitary value
                          Comments

                          For example: eligible percentage or co-payment percentage.

                          Control10..1
                          Typedecimal
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          Some adjudication categories convey a percentage or a fixed value.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          106. ExplanationOfBenefit.item.adjudication:denialreason
                          Slice Namedenialreason
                          Definition

                          If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                          ShortAdjudication details
                          Control0..*
                          TypeBackboneElement
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          108. ExplanationOfBenefit.item.adjudication:denialreason.modifierExtension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                          Summarytrue
                          Requirements

                          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                          Alternate Namesextensions, user content, modifiers
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          110. ExplanationOfBenefit.item.adjudication:denialreason.category
                          Definition

                          A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                          ShortType of adjudication information
                          Comments

                          For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                          Control1..1
                          BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
                          (example to http://hl7.org/fhir/ValueSet/adjudication)

                          The adjudication codes.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Needed to enable understanding of the context of the other information in the adjudication.

                          Pattern Value{
                            "coding" : [{
                              "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                              "code" : "denialreason"
                            }]
                          }
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          112. ExplanationOfBenefit.item.adjudication:denialreason.reason
                          Definition

                          A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                          ShortExplanation of adjudication outcome
                          Comments

                          For example, may indicate that the funds for this benefit type have been exhausted.

                          Control10..1
                          BindingThe codes SHALL be taken from For example codes, see X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codeshttp://hl7.org/fhir/ValueSet/adjudication-reason
                          (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes)
                          TypeCodeableConcept
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          To support understanding of variance from adjudication expectations.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          114. ExplanationOfBenefit.item.adjudication:consumedunits
                          Slice Nameconsumedunits
                          Definition

                          If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                          ShortAdjudication details
                          Control0..1*
                          TypeBackboneElement
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          116. ExplanationOfBenefit.item.adjudication:consumedunits.modifierExtension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                          Summarytrue
                          Requirements

                          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                          Alternate Namesextensions, user content, modifiers
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          118. ExplanationOfBenefit.item.adjudication:consumedunits.category
                          Definition

                          A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                          ShortType of adjudication information
                          Comments

                          For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                          Control1..1
                          BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
                          (example to http://hl7.org/fhir/ValueSet/adjudication)

                          The adjudication codes.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Needed to enable understanding of the context of the other information in the adjudication.

                          Pattern Value{
                            "coding" : [{
                              "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                              "code" : "consumedunits"
                            }]
                          }
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          120. ExplanationOfBenefit.item.adjudication:consumedunits.value
                          Definition

                          A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                          ShortNon-monitary value
                          Comments

                          For example: eligible percentage or co-payment percentage.

                          Control10..1
                          Typedecimal
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summaryfalse
                          Requirements

                          Some adjudication categories convey a percentage or a fixed value.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          122. ExplanationOfBenefit.adjudication
                          Definition

                          The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

                          ShortHeader-level adjudication
                          Control0..*
                          TypeBackboneElement
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices areUnordered and Closed, and can be differentiated using the following discriminators:
                          • pattern @ category
                          • 124. ExplanationOfBenefit.adjudication.extension
                            Definition

                            An Extension


                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                            ShortExtensionAdditional content defined by implementations
                            Comments

                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                            Control0..*
                            TypeExtension
                            Is Modifierfalse
                            Summaryfalse
                            Alternate Namesextensions, user content
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                            • value @ url
                            • 126. ExplanationOfBenefit.adjudication.extension:reviewAction
                              Slice NamereviewAction
                              Definition

                              The details of the review action that is necessary for the authorization.

                              ShortThe details of the review action that is necessary for the authorization for the entire request.
                              Control0..1
                              This element is affected by the following invariants: ele-1
                              TypeExtension(ReviewAction) (Complex Extension)
                              Is Modifierfalse
                              Must Supporttrue
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              128. ExplanationOfBenefit.adjudication.extension:adjudicationActionDate
                              Slice NameadjudicationActionDate
                              Definition

                              Date and Time when Adjudication Action took place. NOTE: that this extension may be replaced by an inter-version extension after R6 version of the EOB implements this DataTime element.

                              ShortThe date/time when an Adjudication Action occured.
                              Control0..1
                              This element is affected by the following invariants: ele-1
                              TypeExtension(When Adjudicated) (Extension Type: dateTime)
                              Is Modifierfalse
                              Must Supporttrue
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              130. ExplanationOfBenefit.adjudication.modifierExtension
                              Definition

                              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                              ShortExtensions that cannot be ignored even if unrecognized
                              Comments

                              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                              Control0..*
                              TypeExtension
                              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                              Summarytrue
                              Requirements

                              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                              Alternate Namesextensions, user content, modifiers
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              132. ExplanationOfBenefit.adjudication.category
                              Definition

                              A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                              ShortType of adjudication information
                              Comments

                              For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                              Control1..1
                              BindingThe codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminatorhttp://hl7.org/fhir/ValueSet/adjudication
                              (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator)
                              TypeCodeableConcept
                              Is Modifierfalse
                              Must Supporttrue
                              Summaryfalse
                              Requirements

                              Needed to enable understanding of the context of the other information in the adjudication.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              134. ExplanationOfBenefit.adjudication:adjudicationamounttype
                              Slice Nameadjudicationamounttype
                              Definition

                              The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

                              ShortHeader-level adjudication
                              Control0..*
                              TypeBackboneElement
                              Is Modifierfalse
                              Must Supporttrue
                              Summaryfalse
                              Requirements

                              Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              136. ExplanationOfBenefit.adjudication:adjudicationamounttype.modifierExtension
                              Definition

                              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                              ShortExtensions that cannot be ignored even if unrecognized
                              Comments

                              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                              Control0..*
                              TypeExtension
                              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                              Summarytrue
                              Requirements

                              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                              Alternate Namesextensions, user content, modifiers
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              138. ExplanationOfBenefit.adjudication:adjudicationamounttype.category
                              Definition

                              A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                              ShortType of adjudication information
                              Comments

                              For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                              Control1..1
                              BindingThe codes SHALL be taken from For example codes, see PDex Adjudicationhttp://hl7.org/fhir/ValueSet/adjudication
                              (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication)
                              TypeCodeableConcept
                              Is Modifierfalse
                              Summaryfalse
                              Requirements

                              Needed to enable understanding of the context of the other information in the adjudication.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              140. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
                              Definition

                              Monetary amount associated with the category.

                              ShortMonetary amount
                              Comments

                              For example, amount submitted, eligible amount, co-payment, and benefit payable.

                              Control10..1
                              TypeMoney
                              Is Modifierfalse
                              Summaryfalse
                              Requirements

                              Most adjuciation categories convey a monetary amount.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              142. ExplanationOfBenefit.adjudication:denialreason
                              Slice Namedenialreason
                              Definition

                              The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

                              ShortHeader-level adjudication
                              Control0..*
                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                              Is Modifierfalse
                              Must Supporttrue
                              Summaryfalse
                              Requirements

                              Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              144. ExplanationOfBenefit.total
                              Definition

                              Categorized monetary totals for the adjudication.

                              ShortAdjudication totals
                              Comments

                              Totals for amounts submitted, co-pays, benefits payable etc.

                              Control0..*
                              TypeBackboneElement
                              Is Modifierfalse
                              Summarytrue
                              Requirements

                              To provide the requestor with financial totals by category for the adjudication.

                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              146. ExplanationOfBenefit.total.extension
                              Definition

                              An Extension


                              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                              ShortExtensionAdditional content defined by implementations
                              Comments

                              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                              Control0..*
                              TypeExtension
                              Is Modifierfalse
                              Summaryfalse
                              Alternate Namesextensions, user content
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              SlicingThis element introduces a set of slices on ExplanationOfBenefit.total.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                              • value @ url
                              • 148. ExplanationOfBenefit.total.extension:priorauth-utilization
                                Slice Namepriorauth-utilization
                                Definition

                                Attribute that expresses the amount of an item or service that has been consumed under the current prior authorization.

                                ShortAn attribute to express the amount of a service or item that has been utilized
                                Control0..1
                                This element is affected by the following invariants: ele-1
                                TypeExtension(An attribute to express the amount of a service or item that has been utilized) (Extension Type: Choice of: Quantity, Ratio)
                                Is Modifierfalse
                                Must Supporttrue
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                150. ExplanationOfBenefit.total.modifierExtension
                                Definition

                                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

                                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                Control0..*
                                TypeExtension
                                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                Summarytrue
                                Requirements

                                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                Alternate Namesextensions, user content, modifiers
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                152. ExplanationOfBenefit.total.category
                                Definition

                                A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                ShortPrior Authorization utilization codesType of adjudication information
                                Comments

                                For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                Control1..1
                                BindingUnless not suitable, these codes SHALL be taken from For example codes, see Prior Authorization value categorieshttp://hl7.org/fhir/ValueSet/adjudication
                                (extensible to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts)
                                TypeCodeableConcept
                                Is Modifierfalse
                                Must Supporttrue
                                Summarytrue
                                Requirements

                                Needed to convey the type of total provided.

                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                154. ExplanationOfBenefit.total.amount
                                Definition

                                Monetary total amount associated with the category.

                                ShortFinancial total for the category
                                Control1..1
                                TypeMoney
                                Is Modifierfalse
                                Summarytrue
                                Requirements

                                Needed to convey the total monetary amount.

                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

                                Guidance on how to interpret the contents of this table can be found here

                                0. ExplanationOfBenefit
                                Definition

                                This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

                                ShortExplanation of Benefit resource
                                Control0..*
                                Is Modifierfalse
                                Summaryfalse
                                Alternate NamesEOB
                                Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
                                dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
                                dom-6: A resource should have narrative for robust management (text.`div`.exists())
                                adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice ((adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()))
                                2. ExplanationOfBenefit.id
                                Definition

                                The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

                                ShortLogical id of this artifact
                                Comments

                                The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

                                Control0..1
                                Typeid
                                Is Modifierfalse
                                Summarytrue
                                4. ExplanationOfBenefit.meta
                                Definition

                                The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

                                ShortMetadata about the resource
                                Control0..1
                                TypeMeta
                                Is Modifierfalse
                                Summarytrue
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                6. ExplanationOfBenefit.meta.id
                                Definition

                                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                ShortUnique id for inter-element referencing
                                Control0..1
                                Typestring
                                Is Modifierfalse
                                XML FormatIn the XML format, this property is represented as an attribute.
                                Summaryfalse
                                8. ExplanationOfBenefit.meta.extension
                                Definition

                                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                ShortAdditional content defined by implementations
                                Comments

                                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                Control0..*
                                TypeExtension
                                Is Modifierfalse
                                Summaryfalse
                                Alternate Namesextensions, user content
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                SlicingThis element introduces a set of slices on ExplanationOfBenefit.meta.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                • value @ url
                                • 10. ExplanationOfBenefit.meta.versionId
                                  Definition

                                  The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

                                  ShortVersion specific identifier
                                  Comments

                                  The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

                                  Control0..1
                                  Typeid
                                  Is Modifierfalse
                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                  Summarytrue
                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                  12. ExplanationOfBenefit.meta.lastUpdated
                                  Definition

                                  When the resource last changed - e.g. when the version changed.

                                  ShortWhen the resource version last changed
                                  Comments

                                  This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

                                  Control0..1
                                  Typeinstant
                                  Is Modifierfalse
                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                  Summarytrue
                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                  14. ExplanationOfBenefit.meta.source
                                  Definition

                                  A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

                                  ShortIdentifies where the resource comes from
                                  Comments

                                  In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

                                  This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

                                  Control0..1
                                  Typeuri
                                  Is Modifierfalse
                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                  Summarytrue
                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                  16. ExplanationOfBenefit.meta.profile
                                  Definition

                                  A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

                                  ShortProfiles this resource claims to conform to
                                  Comments

                                  It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

                                  Control1..*
                                  Typecanonical(StructureDefinition)
                                  Is Modifierfalse
                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                  Summarytrue
                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                  SlicingThis element introduces a set of slices on ExplanationOfBenefit.meta.profile. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                  • pattern @ $this
                                  • 18. ExplanationOfBenefit.meta.profile:supportedProfile
                                    Slice NamesupportedProfile
                                    Definition

                                    A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

                                    ShortProfiles this resource claims to conform to
                                    Comments

                                    It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

                                    Control1..1
                                    Typecanonical(StructureDefinition)
                                    Is Modifierfalse
                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                    Summarytrue
                                    Pattern Valuehttp://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    20. ExplanationOfBenefit.meta.security
                                    Definition

                                    Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

                                    ShortSecurity Labels applied to this resource
                                    Comments

                                    The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

                                    Control0..*
                                    BindingUnless not suitable, these codes SHALL be taken from All Security Labels
                                    (extensible to http://hl7.org/fhir/ValueSet/security-labels)

                                    Security Labels from the Healthcare Privacy and Security Classification System.

                                    TypeCoding
                                    Is Modifierfalse
                                    Summarytrue
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    22. ExplanationOfBenefit.meta.tag
                                    Definition

                                    Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

                                    ShortTags applied to this resource
                                    Comments

                                    The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

                                    Control0..*
                                    BindingFor example codes, see CommonTags
                                    (example to http://hl7.org/fhir/ValueSet/common-tags)

                                    Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

                                    TypeCoding
                                    Is Modifierfalse
                                    Summarytrue
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    24. ExplanationOfBenefit.implicitRules
                                    Definition

                                    A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

                                    ShortA set of rules under which this content was created
                                    Comments

                                    Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

                                    Control0..1
                                    Typeuri
                                    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                    Summarytrue
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    26. ExplanationOfBenefit.language
                                    Definition

                                    The base language in which the resource is written.

                                    ShortLanguage of the resource content
                                    Comments

                                    Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

                                    Control0..1
                                    BindingThe codes SHOULD be taken from CommonLanguages
                                    (preferred to http://hl7.org/fhir/ValueSet/languages)

                                    A human language.

                                    Additional BindingsPurpose
                                    AllLanguagesMax Binding
                                    Typecode
                                    Is Modifierfalse
                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                    Summaryfalse
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    28. ExplanationOfBenefit.text
                                    Definition

                                    A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

                                    ShortText summary of the resource, for human interpretation
                                    Comments

                                    Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

                                    Control0..1
                                    TypeNarrative
                                    Is Modifierfalse
                                    Summaryfalse
                                    Alternate Namesnarrative, html, xhtml, display
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    30. ExplanationOfBenefit.contained
                                    Definition

                                    These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

                                    ShortContained, inline Resources
                                    Comments

                                    This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

                                    Control0..*
                                    TypeResource
                                    Is Modifierfalse
                                    Summaryfalse
                                    Alternate Namesinline resources, anonymous resources, contained resources
                                    32. ExplanationOfBenefit.extension
                                    Definition

                                    An Extension

                                    ShortExtension
                                    Control0..*
                                    TypeExtension
                                    Is Modifierfalse
                                    Summaryfalse
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                    • value @ url
                                    • 34. ExplanationOfBenefit.extension:levelOfServiceType
                                      Slice NamelevelOfServiceType
                                      Definition

                                      A code specifying the level of service being requested (UM06)

                                      ShortA code specifying the level of service being requested (UM06)
                                      Control0..1
                                      This element is affected by the following invariants: ele-1
                                      TypeExtension(LevelOfServiceCode) (Extension Type: CodeableConcept)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      36. ExplanationOfBenefit.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
                                      Summaryfalse
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      38. ExplanationOfBenefit.identifier
                                      Definition

                                      A unique identifier assigned to this explanation of benefit.

                                      ShortBusiness Identifier for the resource
                                      NoteThis is a business identifier, not a resource identifier (see discussion)
                                      Control0..*
                                      TypeIdentifier
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Allows EOBs to be distinguished and referenced.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      40. ExplanationOfBenefit.status
                                      Definition

                                      The status of the resource instance.

                                      Shortactive | cancelled | draft | entered-in-error
                                      Comments

                                      This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

                                      Control1..1
                                      BindingThe codes SHALL be taken from ExplanationOfBenefitStatus
                                      (required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1)

                                      A code specifying the state of the resource instance.

                                      Typecode
                                      Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      42. ExplanationOfBenefit.type
                                      Definition

                                      The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

                                      ShortCategory or discipline
                                      Comments

                                      The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

                                      Control1..1
                                      BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
                                      (extensible to http://hl7.org/fhir/ValueSet/claim-type)

                                      The type or discipline-style of the claim.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      Claim type determine the general sets of business rules applied for information requirements and adjudication.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      44. ExplanationOfBenefit.subType
                                      Definition

                                      A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

                                      ShortMore granular claim type
                                      Comments

                                      This may contain the local bill type codes such as the US UB-04 bill type code.

                                      Control0..1
                                      BindingFor example codes, see ExampleClaimSubTypeCodes
                                      (example to http://hl7.org/fhir/ValueSet/claim-subtype)

                                      A more granular claim typecode.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Some jurisdictions need a finer grained claim type for routing and adjudication.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      46. ExplanationOfBenefit.use
                                      Definition

                                      A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

                                      Shortclaim | preauthorization | predetermination
                                      Control1..1
                                      BindingThe codes SHALL be taken from Use
                                      (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

                                      Complete, proposed, exploratory, other.

                                      Typecode
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      This element is required to understand the nature of the request for adjudication.

                                      Pattern Valuepreauthorization
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      48. ExplanationOfBenefit.patient
                                      Definition

                                      The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

                                      ShortThe recipient of the products and services
                                      Control1..1
                                      TypeReference(US Core Patient Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      50. ExplanationOfBenefit.billablePeriod
                                      Definition

                                      The period for which charges are being submitted.

                                      ShortRelevant time frame for the claim
                                      Comments

                                      Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

                                      Control0..1
                                      TypePeriod
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      52. ExplanationOfBenefit.created
                                      Definition

                                      The date this resource was created.

                                      ShortResponse creation date
                                      Comments

                                      This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

                                      Control1..1
                                      TypedateTime
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summarytrue
                                      Requirements

                                      Need to record a timestamp for use by both the recipient and the issuer.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      54. ExplanationOfBenefit.enterer
                                      Definition

                                      Individual who created the claim, predetermination or preauthorization.

                                      ShortAuthor of the claim
                                      Control0..1
                                      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Must Support TypesNo must-support rules about the choice of types/profiles
                                      Summaryfalse
                                      Requirements

                                      Some jurisdictions require the contact information for personnel completing claims.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      56. ExplanationOfBenefit.insurer
                                      Definition

                                      The party responsible for authorization, adjudication and reimbursement.

                                      ShortParty responsible for reimbursement
                                      Control1..1
                                      TypeReference(US Core Organization Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      58. ExplanationOfBenefit.provider
                                      Definition

                                      The provider which is responsible for the claim, predetermination or preauthorization.

                                      ShortParty responsible for the claim
                                      Comments

                                      Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

                                      Control1..1
                                      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Must Support TypesNo must-support rules about the choice of types/profiles
                                      Summarytrue
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      60. ExplanationOfBenefit.priority
                                      Definition

                                      The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

                                      ShortDesired processing urgency
                                      Comments

                                      If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

                                      Control0..1
                                      BindingThe codes SHALL be taken from ProcessPriorityCodes
                                      (required to http://hl7.org/fhir/ValueSet/process-priority)
                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      62. ExplanationOfBenefit.fundsReserveRequested
                                      Definition

                                      A code to indicate whether and for whom funds are to be reserved for future claims.

                                      ShortFor whom to reserve funds
                                      Comments

                                      This field is only used for preauthorizations.

                                      Control0..1
                                      BindingFor example codes, see Funds Reservation Codes
                                      (example to http://hl7.org/fhir/ValueSet/fundsreserve)

                                      For whom funds are to be reserved: (Patient, Provider, None).

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

                                      Alternate NamesFund pre-allocation
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      64. ExplanationOfBenefit.fundsReserve
                                      Definition

                                      A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

                                      ShortFunds reserved status
                                      Comments

                                      Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

                                      Control0..1
                                      BindingFor example codes, see Funds Reservation Codes
                                      (example to http://hl7.org/fhir/ValueSet/fundsreserve)

                                      For whom funds are to be reserved: (Patient, Provider, None).

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      66. ExplanationOfBenefit.related
                                      Definition

                                      Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

                                      ShortPrior or corollary claims
                                      Comments

                                      For example, for the original treatment and follow-up exams.

                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      For workplace or other accidents it is common to relate separate claims arising from the same event.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      68. ExplanationOfBenefit.related.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      70. ExplanationOfBenefit.related.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      72. ExplanationOfBenefit.related.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      74. ExplanationOfBenefit.related.claim
                                      Definition

                                      Reference to a related claim.

                                      ShortReference to the related claim
                                      Control0..1
                                      TypeReference(Claim)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      For workplace or other accidents it is common to relate separate claims arising from the same event.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      76. ExplanationOfBenefit.related.relationship
                                      Definition

                                      A code to convey how the claims are related.

                                      ShortHow the reference claim is related
                                      Comments

                                      For example, prior claim or umbrella.

                                      Control0..1
                                      BindingFor example codes, see ExampleRelatedClaimRelationshipCodes
                                      (example to http://hl7.org/fhir/ValueSet/related-claim-relationship)

                                      Relationship of this claim to a related Claim.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Some insurers need a declaration of the type of relationship.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      78. ExplanationOfBenefit.related.reference
                                      Definition

                                      An alternate organizational reference to the case or file to which this particular claim pertains.

                                      ShortFile or case reference
                                      Comments

                                      For example, Property/Casualty insurer claim number or Workers Compensation case number.

                                      Control0..1
                                      TypeIdentifier
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      80. ExplanationOfBenefit.prescription
                                      Definition

                                      Prescription to support the dispensing of pharmacy, device or vision products.

                                      ShortPrescription authorizing services or products
                                      Control0..1
                                      TypeReference(MedicationRequest, VisionPrescription)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required to authorize the dispensing of controlled substances and devices.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      82. ExplanationOfBenefit.originalPrescription
                                      Definition

                                      Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

                                      ShortOriginal prescription if superceded by fulfiller
                                      Comments

                                      For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

                                      Control0..1
                                      TypeReference(MedicationRequest)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      84. ExplanationOfBenefit.payee
                                      Definition

                                      The party to be reimbursed for cost of the products and services according to the terms of the policy.

                                      ShortRecipient of benefits payable
                                      Comments

                                      Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

                                      Control0..1
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      86. ExplanationOfBenefit.payee.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      88. ExplanationOfBenefit.payee.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      90. ExplanationOfBenefit.payee.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      92. ExplanationOfBenefit.payee.type
                                      Definition

                                      Type of Party to be reimbursed: Subscriber, provider, other.

                                      ShortCategory of recipient
                                      Control0..1
                                      BindingFor example codes, see Claim Payee Type Codes
                                      (example to http://hl7.org/fhir/ValueSet/payeetype)

                                      A code for the party to be reimbursed.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      94. ExplanationOfBenefit.payee.party
                                      Definition

                                      Reference to the individual or organization to whom any payment will be made.

                                      ShortRecipient reference
                                      Comments

                                      Not required if the payee is 'subscriber' or 'provider'.

                                      Control0..1
                                      TypeReference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      96. ExplanationOfBenefit.referral
                                      Definition

                                      A reference to a referral resource.

                                      ShortTreatment Referral
                                      Comments

                                      The referral resource which lists the date, practitioner, reason and other supporting information.

                                      Control0..1
                                      TypeReference(ServiceRequest)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Some insurers require proof of referral to pay for services or to pay specialist rates for services.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      98. ExplanationOfBenefit.facility
                                      Definition

                                      Facility where the services were provided.

                                      ShortServicing Facility
                                      Control0..1
                                      TypeReference(US Core Location Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summaryfalse
                                      Requirements

                                      Insurance adjudication can be dependant on where services were delivered.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      100. ExplanationOfBenefit.claim
                                      Definition

                                      The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

                                      ShortClaim reference
                                      Control0..1
                                      TypeReference(Claim)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      To provide a link to the original adjudication request.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      102. ExplanationOfBenefit.claimResponse
                                      Definition

                                      The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

                                      ShortClaim response reference
                                      Control0..1
                                      TypeReference(ClaimResponse)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      To provide a link to the original adjudication response.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      104. ExplanationOfBenefit.outcome
                                      Definition

                                      The outcome of the claim, predetermination, or preauthorization processing.

                                      Shortqueued | complete | error | partial
                                      Comments

                                      The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

                                      Control1..1
                                      BindingThe codes SHALL be taken from ClaimProcessingCodes
                                      (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

                                      The result of the claim processing.

                                      Typecode
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summarytrue
                                      Requirements

                                      To advise the requestor of an overall processing outcome.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      106. ExplanationOfBenefit.disposition
                                      Definition

                                      A human readable description of the status of the adjudication.

                                      ShortDisposition Message
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Provided for user display.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      108. ExplanationOfBenefit.preAuthRef
                                      Definition

                                      Reference from the Insurer which is used in later communications which refers to this adjudication.

                                      ShortPreauthorization reference
                                      Comments

                                      This value is only present on preauthorization adjudications.

                                      Control0..*
                                      Typestring
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      On subsequent claims, the insurer may require the provider to quote this value.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      110. ExplanationOfBenefit.preAuthRefPeriod
                                      Definition

                                      The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

                                      ShortPreauthorization in-effect period
                                      Comments

                                      Prior Authorization in-effect period

                                      Control0..1
                                      TypePeriod
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summaryfalse
                                      Requirements

                                      On subsequent claims, the insurer may require the provider to quote this value.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      112. ExplanationOfBenefit.careTeam
                                      Definition

                                      The members of the team who provided the products and services.

                                      ShortCare Team members
                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Common to identify the responsible and supporting practitioners.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      114. ExplanationOfBenefit.careTeam.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      116. ExplanationOfBenefit.careTeam.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      118. ExplanationOfBenefit.careTeam.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      120. ExplanationOfBenefit.careTeam.sequence
                                      Definition

                                      A number to uniquely identify care team entries.

                                      ShortOrder of care team
                                      Control1..1
                                      TypepositiveInt
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      122. ExplanationOfBenefit.careTeam.provider
                                      Definition

                                      Member of the team who provided the product or service.

                                      ShortPractitioner or organization
                                      Control1..1
                                      TypeReference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Must Support TypesNo must-support rules about the choice of types/profiles
                                      Summaryfalse
                                      Requirements

                                      Often a regulatory requirement to specify the responsible provider.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      124. ExplanationOfBenefit.careTeam.responsible
                                      Definition

                                      The party who is billing and/or responsible for the claimed products or services.

                                      ShortIndicator of the lead practitioner
                                      Comments

                                      Responsible might not be required when there is only a single provider listed.

                                      Control0..1
                                      Typeboolean
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      When multiple parties are present it is required to distinguish the lead or responsible individual.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      126. ExplanationOfBenefit.careTeam.role
                                      Definition

                                      The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

                                      ShortFunction within the team
                                      Comments

                                      Role might not be required when there is only a single provider listed.

                                      Control0..1
                                      BindingFor example codes, see ClaimCareTeamRoleCodes
                                      (example to http://hl7.org/fhir/ValueSet/claim-careteamrole)

                                      The role codes for the care team members.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      When multiple parties are present it is required to distinguish the roles performed by each member.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      128. ExplanationOfBenefit.careTeam.qualification
                                      Definition

                                      The qualification of the practitioner which is applicable for this service.

                                      ShortPractitioner credential or specialization
                                      Control0..1
                                      BindingFor example codes, see ExampleProviderQualificationCodes
                                      (example to http://hl7.org/fhir/ValueSet/provider-qualification)

                                      Provider professional qualifications.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Need to specify which qualification a provider is delivering the product or service under.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      130. ExplanationOfBenefit.supportingInfo
                                      Definition

                                      Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

                                      ShortSupporting information
                                      Comments

                                      Often there are multiple jurisdiction specific valuesets which are required.

                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      132. ExplanationOfBenefit.supportingInfo.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      134. ExplanationOfBenefit.supportingInfo.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      136. ExplanationOfBenefit.supportingInfo.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      138. ExplanationOfBenefit.supportingInfo.sequence
                                      Definition

                                      A number to uniquely identify supporting information entries.

                                      ShortInformation instance identifier
                                      Control1..1
                                      TypepositiveInt
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      140. ExplanationOfBenefit.supportingInfo.category
                                      Definition

                                      The general class of the information supplied: information; exception; accident, employment; onset, etc.

                                      ShortClassification of the supplied information
                                      Comments

                                      This may contain a category for the local bill type codes.

                                      Control1..1
                                      BindingFor example codes, see ClaimInformationCategoryCodes
                                      (example to http://hl7.org/fhir/ValueSet/claim-informationcategory)

                                      The valuset used for additional information category codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      142. ExplanationOfBenefit.supportingInfo.code
                                      Definition

                                      System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

                                      ShortType of information
                                      Comments

                                      This may contain the local bill type codes such as the US UB-04 bill type code.

                                      Control0..1
                                      BindingFor example codes, see ExceptionCodes
                                      (example to http://hl7.org/fhir/ValueSet/claim-exception)

                                      The valuset used for additional information codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required to identify the kind of additional information.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      144. ExplanationOfBenefit.supportingInfo.timing[x]
                                      Definition

                                      The date when or period to which this information refers.

                                      ShortWhen it occurred
                                      Control0..1
                                      TypeChoice of: date, Period
                                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      146. ExplanationOfBenefit.supportingInfo.value[x]
                                      Definition

                                      Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

                                      ShortData to be provided
                                      Comments

                                      Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

                                      Control0..1
                                      TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource)
                                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      To convey the data content to be provided when the information is more than a simple code or period.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      148. ExplanationOfBenefit.supportingInfo.reason
                                      Definition

                                      Provides the reason in the situation where a reason code is required in addition to the content.

                                      ShortExplanation for the information
                                      Comments

                                      For example: the reason for the additional stay, or why a tooth is missing.

                                      Control0..1
                                      BindingFor example codes, see MissingToothReasonCodes
                                      (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason)

                                      Reason codes for the missing teeth.

                                      TypeCoding
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Needed when the supporting information has both a date and amount/value and requires explanation.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      150. ExplanationOfBenefit.diagnosis
                                      Definition

                                      Information about diagnoses relevant to the claim items.

                                      ShortPertinent diagnosis information
                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required for the adjudication by provided context for the services and product listed.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      152. ExplanationOfBenefit.diagnosis.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      154. ExplanationOfBenefit.diagnosis.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      156. ExplanationOfBenefit.diagnosis.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      158. ExplanationOfBenefit.diagnosis.sequence
                                      Definition

                                      A number to uniquely identify diagnosis entries.

                                      ShortDiagnosis instance identifier
                                      Comments

                                      Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

                                      Control1..1
                                      TypepositiveInt
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      160. ExplanationOfBenefit.diagnosis.diagnosis[x]
                                      Definition

                                      The nature of illness or problem in a coded form or as a reference to an external defined Condition.

                                      ShortNature of illness or problem
                                      Control1..1
                                      BindingFor example codes, see ICD-10Codes
                                      (example to http://hl7.org/fhir/ValueSet/icd-10)

                                      ICD10 Diagnostic codes.

                                      TypeChoice of: CodeableConcept, Reference(Condition)
                                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Provides health context for the evaluation of the products and/or services.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      162. ExplanationOfBenefit.diagnosis.type
                                      Definition

                                      When the condition was observed or the relative ranking.

                                      ShortTiming or nature of the diagnosis
                                      Comments

                                      For example: admitting, primary, secondary, discharge.

                                      Control0..*
                                      BindingFor example codes, see ExampleDiagnosisTypeCodes
                                      (example to http://hl7.org/fhir/ValueSet/ex-diagnosistype)

                                      The type of the diagnosis: admitting, principal, discharge.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Often required to capture a particular diagnosis, for example: primary or discharge.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      164. ExplanationOfBenefit.diagnosis.onAdmission
                                      Definition

                                      Indication of whether the diagnosis was present on admission to a facility.

                                      ShortPresent on admission
                                      Control0..1
                                      BindingFor example codes, see ExampleDiagnosisOnAdmissionCodes
                                      (example to http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission)

                                      Present on admission.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Many systems need to understand for adjudication if the diagnosis was present a time of admission.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      166. ExplanationOfBenefit.diagnosis.packageCode
                                      Definition

                                      A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

                                      ShortPackage billing code
                                      Comments

                                      For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

                                      Control0..1
                                      BindingFor example codes, see ExampleDiagnosisRelatedGroupCodes
                                      (example to http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup)

                                      The DRG codes associated with the diagnosis.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      168. ExplanationOfBenefit.procedure
                                      Definition

                                      Procedures performed on the patient relevant to the billing items with the claim.

                                      ShortClinical procedures performed
                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      170. ExplanationOfBenefit.procedure.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      172. ExplanationOfBenefit.procedure.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      174. ExplanationOfBenefit.procedure.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      176. ExplanationOfBenefit.procedure.sequence
                                      Definition

                                      A number to uniquely identify procedure entries.

                                      ShortProcedure instance identifier
                                      Control1..1
                                      TypepositiveInt
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Necessary to provide a mechanism to link to claim details.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      178. ExplanationOfBenefit.procedure.type
                                      Definition

                                      When the condition was observed or the relative ranking.

                                      ShortCategory of Procedure
                                      Control0..*
                                      BindingFor example codes, see ExampleProcedureTypeCodes
                                      (example to http://hl7.org/fhir/ValueSet/ex-procedure-type)

                                      Example procedure type codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Often required to capture a particular diagnosis, for example: primary or discharge.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      180. ExplanationOfBenefit.procedure.date
                                      Definition

                                      Date and optionally time the procedure was performed.

                                      ShortWhen the procedure was performed
                                      Control0..1
                                      TypedateTime
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Required for auditing purposes.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      182. ExplanationOfBenefit.procedure.procedure[x]
                                      Definition

                                      The code or reference to a Procedure resource which identifies the clinical intervention performed.

                                      ShortSpecific clinical procedure
                                      Control1..1
                                      BindingFor example codes, see ICD-10ProcedureCodes
                                      (example to http://hl7.org/fhir/ValueSet/icd-10-procedures)

                                      ICD10 Procedure codes.

                                      TypeChoice of: CodeableConcept, Reference(Procedure)
                                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      This identifies the actual clinical procedure.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      184. ExplanationOfBenefit.procedure.udi
                                      Definition

                                      Unique Device Identifiers associated with this line item.

                                      ShortUnique device identifier
                                      Control0..*
                                      TypeReference(Device)
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      The UDI code allows the insurer to obtain device level information on the product supplied.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      186. ExplanationOfBenefit.precedence
                                      Definition

                                      This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.

                                      ShortPrecedence (primary, secondary, etc.)
                                      Control0..1
                                      TypepositiveInt
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Needed to coordinate between multiple EOBs for the same suite of services.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      188. ExplanationOfBenefit.insurance
                                      Definition

                                      Financial instruments for reimbursement for the health care products and services specified on the claim.

                                      ShortPatient insurance information
                                      Comments

                                      All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

                                      Control1..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      At least one insurer is required for a claim to be a claim.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      190. ExplanationOfBenefit.insurance.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      192. ExplanationOfBenefit.insurance.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      194. ExplanationOfBenefit.insurance.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      196. ExplanationOfBenefit.insurance.focal
                                      Definition

                                      A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

                                      ShortCoverage to be used for adjudication
                                      Comments

                                      A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

                                      Control1..1
                                      Typeboolean
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summarytrue
                                      Requirements

                                      To identify which coverage in the list is being used to adjudicate this claim.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      198. ExplanationOfBenefit.insurance.coverage
                                      Definition

                                      Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

                                      ShortInsurance information
                                      Control1..1
                                      TypeReference(HRex Coverage Profile)
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Required to allow the adjudicator to locate the correct policy and history within their information system.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      200. ExplanationOfBenefit.insurance.preAuthRef
                                      Definition

                                      Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

                                      ShortPrior authorization reference number
                                      Comments

                                      This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

                                      Control0..*
                                      Typestring
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      202. ExplanationOfBenefit.accident
                                      Definition

                                      Details of a accident which resulted in injuries which required the products and services listed in the claim.

                                      ShortDetails of the event
                                      Control0..1
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      204. ExplanationOfBenefit.accident.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      206. ExplanationOfBenefit.accident.extension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                      ShortAdditional content defined by implementations
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Alternate Namesextensions, user content
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      208. ExplanationOfBenefit.accident.modifierExtension
                                      Definition

                                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

                                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                      Control0..*
                                      TypeExtension
                                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                      Summarytrue
                                      Requirements

                                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      210. ExplanationOfBenefit.accident.date
                                      Definition

                                      Date of an accident event related to the products and services contained in the claim.

                                      ShortWhen the incident occurred
                                      Comments

                                      The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

                                      Control0..1
                                      Typedate
                                      Is Modifierfalse
                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                      Summaryfalse
                                      Requirements

                                      Required for audit purposes and adjudication.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      212. ExplanationOfBenefit.accident.type
                                      Definition

                                      The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

                                      ShortThe nature of the accident
                                      Control0..1
                                      BindingUnless not suitable, these codes SHALL be taken from ActIncidentCode
                                      (extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode)

                                      Type of accident: work place, auto, etc.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Coverage may be dependant on the type of accident.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      214. ExplanationOfBenefit.accident.location[x]
                                      Definition

                                      The physical location of the accident event.

                                      ShortWhere the event occurred
                                      Control0..1
                                      TypeChoice of: Address, Reference(Location)
                                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Required for audit purposes and determination of applicable insurance liability.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      216. ExplanationOfBenefit.item
                                      Definition

                                      A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

                                      ShortProduct or service provided
                                      Control0..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      The items to be processed for adjudication.

                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      218. ExplanationOfBenefit.item.id
                                      Definition

                                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                      ShortUnique id for inter-element referencing
                                      Control0..1
                                      Typestring
                                      Is Modifierfalse
                                      XML FormatIn the XML format, this property is represented as an attribute.
                                      Summaryfalse
                                      220. ExplanationOfBenefit.item.extension
                                      Definition

                                      An Extension

                                      ShortExtension
                                      Control0..*
                                      TypeExtension
                                      Is Modifierfalse
                                      Summaryfalse
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                      • value @ url
                                      • 222. ExplanationOfBenefit.item.extension:itemTraceNumber
                                        Slice NameitemTraceNumber
                                        Definition

                                        Uniquely identifies this claim item. (2000F-TRN)

                                        ShortUniquely identifies this claim item. (2000F-TRN)
                                        Control0..*
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        224. ExplanationOfBenefit.item.extension:preAuthIssueDate
                                        Slice NamepreAuthIssueDate
                                        Definition

                                        The date when this item's preauthorization was issued.

                                        ShortThe date when this item's preauthorization was issued.
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        226. ExplanationOfBenefit.item.extension:preAuthPeriod
                                        Slice NamepreAuthPeriod
                                        Definition

                                        The date/period when this item's preauthorization is valid.

                                        ShortThe date/period when this item's preauthorization is valid.
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        228. ExplanationOfBenefit.item.extension:previousAuthorizationNumber
                                        Slice NamepreviousAuthorizationNumber
                                        Definition

                                        A string assigned by the UMO to an authorized review outcome associated with this service item.

                                        ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(AuthorizationNumber) (Extension Type: string)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        230. ExplanationOfBenefit.item.extension:administrationReferenceNumber
                                        Slice NameadministrationReferenceNumber
                                        Definition

                                        A string assigned by the UMO to the original disallowed review outcome associated with this service item.

                                        ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        232. ExplanationOfBenefit.item.extension:authorizedItemDetail
                                        Slice NameauthorizedItemDetail
                                        Definition

                                        The details of what has been authorized for this item if different from what was requested.

                                        ShortThe details of what has been authorized for this item if different from what was requested.
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ItemAuthorizedDetail) (Complex Extension)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        234. ExplanationOfBenefit.item.extension:authorizedProvider
                                        Slice NameauthorizedProvider
                                        Definition

                                        The specific provider who has been authorized to provide this item.

                                        ShortThe specific provider who has been authorized to provide this item.
                                        Control0..*
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ItemAuthorizedProvider) (Complex Extension)
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        236. ExplanationOfBenefit.item.modifierExtension
                                        Definition

                                        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                        ShortExtensions that cannot be ignored even if unrecognized
                                        Comments

                                        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                        Control0..*
                                        TypeExtension
                                        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                        Summarytrue
                                        Requirements

                                        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                        Alternate Namesextensions, user content, modifiers
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        238. ExplanationOfBenefit.item.sequence
                                        Definition

                                        A number to uniquely identify item entries.

                                        ShortItem instance identifier
                                        Control1..1
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        240. ExplanationOfBenefit.item.careTeamSequence
                                        Definition

                                        Care team members related to this service or product.

                                        ShortApplicable care team members
                                        Control0..*
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Need to identify the individuals and their roles in the provision of the product or service.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        242. ExplanationOfBenefit.item.diagnosisSequence
                                        Definition

                                        Diagnoses applicable for this service or product.

                                        ShortApplicable diagnoses
                                        Control0..*
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Need to related the product or service to the associated diagnoses.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        244. ExplanationOfBenefit.item.procedureSequence
                                        Definition

                                        Procedures applicable for this service or product.

                                        ShortApplicable procedures
                                        Control0..*
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Need to provide any listed specific procedures to support the product or service being claimed.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        246. ExplanationOfBenefit.item.informationSequence
                                        Definition

                                        Exceptions, special conditions and supporting information applicable for this service or product.

                                        ShortApplicable exception and supporting information
                                        Control0..*
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Need to reference the supporting information items that relate directly to this product or service.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        248. ExplanationOfBenefit.item.revenue
                                        Definition

                                        The type of revenue or cost center providing the product and/or service.

                                        ShortRevenue or cost center code
                                        Control0..1
                                        BindingFor example codes, see ExampleRevenueCenterCodes
                                        (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                                        Codes for the revenue or cost centers supplying the service and/or products.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Needed in the processing of institutional claims.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        250. ExplanationOfBenefit.item.category
                                        Definition

                                        Code to identify the general type of benefits under which products and services are provided.

                                        ShortBenefit classification
                                        Comments

                                        Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                                        Control0..1
                                        BindingThe codes SHALL be taken from Prior Authorization Service Type Codes (X12)
                                        (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes)

                                        Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Must Supporttrue
                                        Summaryfalse
                                        Requirements

                                        Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        252. ExplanationOfBenefit.item.productOrService
                                        Definition

                                        When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                                        ShortBilling, service, product, or drug code
                                        Comments

                                        If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                                        Control1..1
                                        BindingThe codes SHALL be taken from Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS
                                        (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS)
                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Necessary to state what was provided or done.

                                        Alternate NamesDrug Code, Bill Code, Service Code
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        254. ExplanationOfBenefit.item.modifier
                                        Definition

                                        Item typification or modifiers codes to convey additional context for the product or service.

                                        ShortProduct or service billing modifiers
                                        Comments

                                        For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

                                        Control0..*
                                        BindingFor example codes, see ModifierTypeCodes
                                        (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                                        Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        To support inclusion of the item for adjudication or to charge an elevated fee.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        256. ExplanationOfBenefit.item.programCode
                                        Definition

                                        Identifies the program under which this may be recovered.

                                        ShortProgram the product or service is provided under
                                        Comments

                                        For example: Neonatal program, child dental program or drug users recovery program.

                                        Control0..*
                                        BindingFor example codes, see ExampleProgramReasonCodes
                                        (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                                        Program specific reason codes.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        258. ExplanationOfBenefit.item.serviced[x]
                                        Definition

                                        The date or dates when the service or product was supplied, performed or completed.

                                        ShortDate or dates of service or product delivery
                                        Control0..1
                                        TypeChoice of: date, Period
                                        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Needed to determine whether the service or product was provided during the term of the insurance coverage.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        260. ExplanationOfBenefit.item.location[x]
                                        Definition

                                        Where the product or service was provided.

                                        ShortPlace of service or where product was supplied
                                        Control0..1
                                        BindingFor example codes, see ExampleServicePlaceCodes
                                        (example to http://hl7.org/fhir/ValueSet/service-place)

                                        Place where the service is rendered.

                                        TypeChoice of: CodeableConcept, Address, Reference(Location)
                                        [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        262. ExplanationOfBenefit.item.quantity
                                        Definition

                                        The number of repetitions of a service or product.

                                        ShortCount of products or services
                                        Control0..1
                                        TypeQuantity(SimpleQuantity)
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Required when the product or service code does not convey the quantity provided.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        264. ExplanationOfBenefit.item.unitPrice
                                        Definition

                                        If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                                        ShortFee, charge or cost per item
                                        Control0..1
                                        TypeMoney
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        The amount charged to the patient by the provider for a single unit.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        266. ExplanationOfBenefit.item.factor
                                        Definition

                                        A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                                        ShortPrice scaling factor
                                        Comments

                                        To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                                        Control0..1
                                        Typedecimal
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        268. ExplanationOfBenefit.item.net
                                        Definition

                                        The quantity times the unit price for an additional service or product or charge.

                                        ShortTotal item cost
                                        Comments

                                        For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                                        Control0..1
                                        TypeMoney
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Provides the total amount claimed for the group (if a grouper) or the line item.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        270. ExplanationOfBenefit.item.udi
                                        Definition

                                        Unique Device Identifiers associated with this line item.

                                        ShortUnique device identifier
                                        Control0..*
                                        TypeReference(Device)
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        The UDI code allows the insurer to obtain device level information on the product supplied.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        272. ExplanationOfBenefit.item.bodySite
                                        Definition

                                        Physical service site on the patient (limb, tooth, etc.).

                                        ShortAnatomical location
                                        Comments

                                        For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

                                        Control0..1
                                        BindingFor example codes, see OralSiteCodes
                                        (example to http://hl7.org/fhir/ValueSet/tooth)

                                        The code for the teeth, quadrant, sextant and arch.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Allows insurer to validate specific procedures.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        274. ExplanationOfBenefit.item.subSite
                                        Definition

                                        A region or surface of the bodySite, e.g. limb region or tooth surface(s).

                                        ShortAnatomical sub-location
                                        Control0..*
                                        BindingFor example codes, see SurfaceCodes
                                        (example to http://hl7.org/fhir/ValueSet/surface)

                                        The code for the tooth surface and surface combinations.

                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Allows insurer to validate specific procedures.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        276. ExplanationOfBenefit.item.encounter
                                        Definition

                                        A billed item may include goods or services provided in multiple encounters.

                                        ShortEncounters related to this billed item
                                        Control0..*
                                        TypeReference(US Core Encounter Profile)
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Used in some jurisdictions to link clinical events to claim items.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        278. ExplanationOfBenefit.item.noteNumber
                                        Definition

                                        The numbers associated with notes below which apply to the adjudication of this item.

                                        ShortApplicable note numbers
                                        Control0..*
                                        TypepositiveInt
                                        Is Modifierfalse
                                        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                        Summaryfalse
                                        Requirements

                                        Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        280. ExplanationOfBenefit.item.adjudication
                                        Definition

                                        If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                                        ShortAdjudication details
                                        Control0..*
                                        TypeBackboneElement
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices areUnordered and Closed, and can be differentiated using the following discriminators:
                                        • pattern @ category
                                        • 282. ExplanationOfBenefit.item.adjudication.id
                                          Definition

                                          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                          ShortUnique id for inter-element referencing
                                          Control0..1
                                          Typestring
                                          Is Modifierfalse
                                          XML FormatIn the XML format, this property is represented as an attribute.
                                          Summaryfalse
                                          284. ExplanationOfBenefit.item.adjudication.extension
                                          Definition

                                          An Extension

                                          ShortExtension
                                          Control0..*
                                          TypeExtension
                                          Is Modifierfalse
                                          Summaryfalse
                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                          SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                          • value @ url
                                          • 286. ExplanationOfBenefit.item.adjudication.extension:reviewAction
                                            Slice NamereviewAction
                                            Definition

                                            The details of the review action that is necessary for the authorization.

                                            ShortThe details of the review action that is necessary for the authorization at the line level.
                                            Control0..1
                                            This element is affected by the following invariants: ele-1
                                            TypeExtension(ReviewAction) (Complex Extension)
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            288. ExplanationOfBenefit.item.adjudication.extension:adjudicationActionDate
                                            Slice NameadjudicationActionDate
                                            Definition

                                            Date and Time when Adjudication Action took place. NOTE: that this extension may be replaced by an inter-version extension after R6 version of the EOB implements this DataTime element.

                                            ShortThe date/time when an Adjudication Action occured.
                                            Control0..1
                                            This element is affected by the following invariants: ele-1
                                            TypeExtension(When Adjudicated) (Extension Type: dateTime)
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            290. ExplanationOfBenefit.item.adjudication.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            292. ExplanationOfBenefit.item.adjudication.category
                                            Definition

                                            A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                            ShortType of adjudication information
                                            Comments

                                            For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                            Control1..1
                                            BindingThe codes SHALL be taken from PDex Adjudication Category Discriminator
                                            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator)
                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed to enable understanding of the context of the other information in the adjudication.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            294. ExplanationOfBenefit.item.adjudication.reason
                                            Definition

                                            A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                                            ShortExplanation of adjudication outcome
                                            Comments

                                            For example, may indicate that the funds for this benefit type have been exhausted.

                                            Control0..1
                                            BindingFor example codes, see AdjudicationReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                                            Adjudication reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support understanding of variance from adjudication expectations.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            296. ExplanationOfBenefit.item.adjudication.amount
                                            Definition

                                            Monetary amount associated with the category.

                                            ShortMonetary amount
                                            Comments

                                            For example, amount submitted, eligible amount, co-payment, and benefit payable.

                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Most adjuciation categories convey a monetary amount.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            298. ExplanationOfBenefit.item.adjudication.value
                                            Definition

                                            A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                                            ShortNon-monitary value
                                            Comments

                                            For example: eligible percentage or co-payment percentage.

                                            Control0..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            Some adjudication categories convey a percentage or a fixed value.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            300. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
                                            Slice Nameadjudicationamounttype
                                            Definition

                                            If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                                            ShortAdjudication details
                                            Control0..*
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            302. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            304. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            306. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            308. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
                                            Definition

                                            A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                            ShortType of adjudication information
                                            Comments

                                            For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                            Control1..1
                                            BindingThe codes SHALL be taken from PDex Adjudication
                                            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication)
                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed to enable understanding of the context of the other information in the adjudication.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            310. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason
                                            Definition

                                            A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                                            ShortExplanation of adjudication outcome
                                            Comments

                                            For example, may indicate that the funds for this benefit type have been exhausted.

                                            Control0..1
                                            BindingFor example codes, see AdjudicationReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                                            Adjudication reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support understanding of variance from adjudication expectations.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            312. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
                                            Definition

                                            Monetary amount associated with the category.

                                            ShortMonetary amount
                                            Comments

                                            For example, amount submitted, eligible amount, co-payment, and benefit payable.

                                            Control1..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            Most adjuciation categories convey a monetary amount.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            314. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.value
                                            Definition

                                            A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                                            ShortNon-monitary value
                                            Comments

                                            For example: eligible percentage or co-payment percentage.

                                            Control0..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            Some adjudication categories convey a percentage or a fixed value.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            316. ExplanationOfBenefit.item.adjudication:allowedunits
                                            Slice Nameallowedunits
                                            Definition

                                            If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                                            ShortAdjudication details
                                            Control0..1
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            318. ExplanationOfBenefit.item.adjudication:allowedunits.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            320. ExplanationOfBenefit.item.adjudication:allowedunits.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            322. ExplanationOfBenefit.item.adjudication:allowedunits.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            324. ExplanationOfBenefit.item.adjudication:allowedunits.category
                                            Definition

                                            A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                            ShortType of adjudication information
                                            Comments

                                            For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                            Control1..1
                                            BindingFor example codes, see AdjudicationValueCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication)

                                            The adjudication codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed to enable understanding of the context of the other information in the adjudication.

                                            Pattern Value{
                                              "coding" : [{
                                                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                                                "code" : "allowedunits"
                                              }]
                                            }
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            326. ExplanationOfBenefit.item.adjudication:allowedunits.reason
                                            Definition

                                            A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                                            ShortExplanation of adjudication outcome
                                            Comments

                                            For example, may indicate that the funds for this benefit type have been exhausted.

                                            Control0..1
                                            BindingFor example codes, see AdjudicationReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                                            Adjudication reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support understanding of variance from adjudication expectations.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            328. ExplanationOfBenefit.item.adjudication:allowedunits.amount
                                            Definition

                                            Monetary amount associated with the category.

                                            ShortMonetary amount
                                            Comments

                                            For example, amount submitted, eligible amount, co-payment, and benefit payable.

                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Most adjuciation categories convey a monetary amount.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            330. ExplanationOfBenefit.item.adjudication:allowedunits.value
                                            Definition

                                            A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                                            ShortNon-monitary value
                                            Comments

                                            For example: eligible percentage or co-payment percentage.

                                            Control1..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            Some adjudication categories convey a percentage or a fixed value.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            332. ExplanationOfBenefit.item.adjudication:denialreason
                                            Slice Namedenialreason
                                            Definition

                                            If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                                            ShortAdjudication details
                                            Control0..*
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            334. ExplanationOfBenefit.item.adjudication:denialreason.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            336. ExplanationOfBenefit.item.adjudication:denialreason.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            338. ExplanationOfBenefit.item.adjudication:denialreason.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            340. ExplanationOfBenefit.item.adjudication:denialreason.category
                                            Definition

                                            A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                            ShortType of adjudication information
                                            Comments

                                            For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                            Control1..1
                                            BindingFor example codes, see AdjudicationValueCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication)

                                            The adjudication codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed to enable understanding of the context of the other information in the adjudication.

                                            Pattern Value{
                                              "coding" : [{
                                                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                                                "code" : "denialreason"
                                              }]
                                            }
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            342. ExplanationOfBenefit.item.adjudication:denialreason.reason
                                            Definition

                                            A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                                            ShortExplanation of adjudication outcome
                                            Comments

                                            For example, may indicate that the funds for this benefit type have been exhausted.

                                            Control1..1
                                            BindingThe codes SHALL be taken from X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes
                                            (required to http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes)
                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Summaryfalse
                                            Requirements

                                            To support understanding of variance from adjudication expectations.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            344. ExplanationOfBenefit.item.adjudication:denialreason.amount
                                            Definition

                                            Monetary amount associated with the category.

                                            ShortMonetary amount
                                            Comments

                                            For example, amount submitted, eligible amount, co-payment, and benefit payable.

                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Most adjuciation categories convey a monetary amount.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            346. ExplanationOfBenefit.item.adjudication:denialreason.value
                                            Definition

                                            A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                                            ShortNon-monitary value
                                            Comments

                                            For example: eligible percentage or co-payment percentage.

                                            Control0..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            Some adjudication categories convey a percentage or a fixed value.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            348. ExplanationOfBenefit.item.adjudication:consumedunits
                                            Slice Nameconsumedunits
                                            Definition

                                            If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

                                            ShortAdjudication details
                                            Control0..1
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            350. ExplanationOfBenefit.item.adjudication:consumedunits.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            352. ExplanationOfBenefit.item.adjudication:consumedunits.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            354. ExplanationOfBenefit.item.adjudication:consumedunits.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            356. ExplanationOfBenefit.item.adjudication:consumedunits.category
                                            Definition

                                            A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                                            ShortType of adjudication information
                                            Comments

                                            For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                                            Control1..1
                                            BindingFor example codes, see AdjudicationValueCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication)

                                            The adjudication codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed to enable understanding of the context of the other information in the adjudication.

                                            Pattern Value{
                                              "coding" : [{
                                                "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator",
                                                "code" : "consumedunits"
                                              }]
                                            }
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            358. ExplanationOfBenefit.item.adjudication:consumedunits.reason
                                            Definition

                                            A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                                            ShortExplanation of adjudication outcome
                                            Comments

                                            For example, may indicate that the funds for this benefit type have been exhausted.

                                            Control0..1
                                            BindingFor example codes, see AdjudicationReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                                            Adjudication reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support understanding of variance from adjudication expectations.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            360. ExplanationOfBenefit.item.adjudication:consumedunits.amount
                                            Definition

                                            Monetary amount associated with the category.

                                            ShortMonetary amount
                                            Comments

                                            For example, amount submitted, eligible amount, co-payment, and benefit payable.

                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Most adjuciation categories convey a monetary amount.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            362. ExplanationOfBenefit.item.adjudication:consumedunits.value
                                            Definition

                                            A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                                            ShortNon-monitary value
                                            Comments

                                            For example: eligible percentage or co-payment percentage.

                                            Control1..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            Some adjudication categories convey a percentage or a fixed value.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            364. ExplanationOfBenefit.item.detail
                                            Definition

                                            Second-tier of goods and services.

                                            ShortAdditional items
                                            Control0..*
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Summaryfalse
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            366. ExplanationOfBenefit.item.detail.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            368. ExplanationOfBenefit.item.detail.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            370. ExplanationOfBenefit.item.detail.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            372. ExplanationOfBenefit.item.detail.sequence
                                            Definition

                                            A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

                                            ShortProduct or service provided
                                            Control1..1
                                            TypepositiveInt
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            The items to be processed for adjudication.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            374. ExplanationOfBenefit.item.detail.revenue
                                            Definition

                                            The type of revenue or cost center providing the product and/or service.

                                            ShortRevenue or cost center code
                                            Control0..1
                                            BindingFor example codes, see ExampleRevenueCenterCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                                            Codes for the revenue or cost centers supplying the service and/or products.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed in the processing of institutional claims.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            376. ExplanationOfBenefit.item.detail.category
                                            Definition

                                            Code to identify the general type of benefits under which products and services are provided.

                                            ShortBenefit classification
                                            Comments

                                            Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                                            Control0..1
                                            BindingFor example codes, see BenefitCategoryCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

                                            Benefit categories such as: oral, medical, vision, oral-basic etc.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            378. ExplanationOfBenefit.item.detail.productOrService
                                            Definition

                                            When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                                            ShortBilling, service, product, or drug code
                                            Comments

                                            If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                                            Control1..1
                                            BindingFor example codes, see USCLSCodes
                                            (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                            Allowable service and product codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Necessary to state what was provided or done.

                                            Alternate NamesDrug Code, Bill Code, Service Code
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            380. ExplanationOfBenefit.item.detail.modifier
                                            Definition

                                            Item typification or modifiers codes to convey additional context for the product or service.

                                            ShortService/Product billing modifiers
                                            Comments

                                            For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

                                            Control0..*
                                            BindingFor example codes, see ModifierTypeCodes
                                            (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                                            Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support inclusion of the item for adjudication or to charge an elevated fee.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            382. ExplanationOfBenefit.item.detail.programCode
                                            Definition

                                            Identifies the program under which this may be recovered.

                                            ShortProgram the product or service is provided under
                                            Comments

                                            For example: Neonatal program, child dental program or drug users recovery program.

                                            Control0..*
                                            BindingFor example codes, see ExampleProgramReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                                            Program specific reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            384. ExplanationOfBenefit.item.detail.quantity
                                            Definition

                                            The number of repetitions of a service or product.

                                            ShortCount of products or services
                                            Control0..1
                                            TypeQuantity(SimpleQuantity)
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Required when the product or service code does not convey the quantity provided.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            386. ExplanationOfBenefit.item.detail.unitPrice
                                            Definition

                                            If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                                            ShortFee, charge or cost per item
                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            The amount charged to the patient by the provider for a single unit.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            388. ExplanationOfBenefit.item.detail.factor
                                            Definition

                                            A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                                            ShortPrice scaling factor
                                            Comments

                                            To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                                            Control0..1
                                            Typedecimal
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            390. ExplanationOfBenefit.item.detail.net
                                            Definition

                                            The quantity times the unit price for an additional service or product or charge.

                                            ShortTotal item cost
                                            Comments

                                            For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                                            Control0..1
                                            TypeMoney
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Provides the total amount claimed for the group (if a grouper) or the line item.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            392. ExplanationOfBenefit.item.detail.udi
                                            Definition

                                            Unique Device Identifiers associated with this line item.

                                            ShortUnique device identifier
                                            Control0..*
                                            TypeReference(Device)
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            The UDI code allows the insurer to obtain device level information on the product supplied.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            394. ExplanationOfBenefit.item.detail.noteNumber
                                            Definition

                                            The numbers associated with notes below which apply to the adjudication of this item.

                                            ShortApplicable note numbers
                                            Control0..*
                                            TypepositiveInt
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            396. ExplanationOfBenefit.item.detail.adjudication
                                            Definition

                                            The adjudication results.

                                            ShortDetail level adjudication details
                                            Control0..*
                                            TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                            Is Modifierfalse
                                            Summaryfalse
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            398. ExplanationOfBenefit.item.detail.subDetail
                                            Definition

                                            Third-tier of goods and services.

                                            ShortAdditional items
                                            Control0..*
                                            TypeBackboneElement
                                            Is Modifierfalse
                                            Summaryfalse
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            400. ExplanationOfBenefit.item.detail.subDetail.id
                                            Definition

                                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                                            ShortUnique id for inter-element referencing
                                            Control0..1
                                            Typestring
                                            Is Modifierfalse
                                            XML FormatIn the XML format, this property is represented as an attribute.
                                            Summaryfalse
                                            402. ExplanationOfBenefit.item.detail.subDetail.extension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                                            ShortAdditional content defined by implementations
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifierfalse
                                            Summaryfalse
                                            Alternate Namesextensions, user content
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            404. ExplanationOfBenefit.item.detail.subDetail.modifierExtension
                                            Definition

                                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                                            ShortExtensions that cannot be ignored even if unrecognized
                                            Comments

                                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                                            Control0..*
                                            TypeExtension
                                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                                            Summarytrue
                                            Requirements

                                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                                            Alternate Namesextensions, user content, modifiers
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            406. ExplanationOfBenefit.item.detail.subDetail.sequence
                                            Definition

                                            A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

                                            ShortProduct or service provided
                                            Control1..1
                                            TypepositiveInt
                                            Is Modifierfalse
                                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                            Summaryfalse
                                            Requirements

                                            The items to be processed for adjudication.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            408. ExplanationOfBenefit.item.detail.subDetail.revenue
                                            Definition

                                            The type of revenue or cost center providing the product and/or service.

                                            ShortRevenue or cost center code
                                            Control0..1
                                            BindingFor example codes, see ExampleRevenueCenterCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                                            Codes for the revenue or cost centers supplying the service and/or products.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed in the processing of institutional claims.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            410. ExplanationOfBenefit.item.detail.subDetail.category
                                            Definition

                                            Code to identify the general type of benefits under which products and services are provided.

                                            ShortBenefit classification
                                            Comments

                                            Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                                            Control0..1
                                            BindingFor example codes, see BenefitCategoryCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

                                            Benefit categories such as: oral, medical, vision, oral-basic etc.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            412. ExplanationOfBenefit.item.detail.subDetail.productOrService
                                            Definition

                                            When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                                            ShortBilling, service, product, or drug code
                                            Comments

                                            If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                                            Control1..1
                                            BindingFor example codes, see USCLSCodes
                                            (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                            Allowable service and product codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Necessary to state what was provided or done.

                                            Alternate NamesDrug Code, Bill Code, Service Code
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            414. ExplanationOfBenefit.item.detail.subDetail.modifier
                                            Definition

                                            Item typification or modifiers codes to convey additional context for the product or service.

                                            ShortService/Product billing modifiers
                                            Comments

                                            For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

                                            Control0..*
                                            BindingFor example codes, see ModifierTypeCodes
                                            (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                                            Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            To support inclusion of the item for adjudication or to charge an elevated fee.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            416. ExplanationOfBenefit.item.detail.subDetail.programCode
                                            Definition

                                            Identifies the program under which this may be recovered.

                                            ShortProgram the product or service is provided under
                                            Comments

                                            For example: Neonatal program, child dental program or drug users recovery program.

                                            Control0..*
                                            BindingFor example codes, see ExampleProgramReasonCodes
                                            (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                                            Program specific reason codes.

                                            TypeCodeableConcept
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            418. ExplanationOfBenefit.item.detail.subDetail.quantity
                                            Definition

                                            The number of repetitions of a service or product.

                                            ShortCount of products or services
                                            Control0..1
                                            TypeQuantity(SimpleQuantity)
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Required when the product or service code does not convey the quantity provided.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            420. ExplanationOfBenefit.item.detail.subDetail.unitPrice