Da Vinci Payer Data Exchange
2.1.1 - STU 2.1

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 2.1.1 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: Informative

Definitions for the pdex-priorauthorization resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

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

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.
Short | Explanation of Benefit resource
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | EOB
Invariants | dom-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.
Short | A 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.
Control | 0..1
Type | uri
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-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.
Short | ExtensionAdditional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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())
Slicing | This 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 Name | levelOfServiceType
Definition | A code specifying the level of service being requested (UM06)
Short | A code specifying the level of service being requested (UM06)
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(LevelOfServiceCode) (Extension Type: CodeableConcept)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
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 Names | extensions, user content
Invariants | ele-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.
Short | active | 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.
Control | 1..1
Binding | The codes SHALL be taken from ExplanationOfBenefitStatus http://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.
Type | code
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
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'.
Invariants | ele-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.
Short | Category 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.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Invariants | ele-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.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use http://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.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Pattern Value | `preauthorization`
Invariants | ele-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.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile, Patient)
Is Modifier | false
Must Support | true
Summary | true
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.
Invariants | ele-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.
Short | Response 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.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-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.
Short | Author of the claim
Control | 0..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, Practitioner, PractitionerRole)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Some jurisdictions require the contact information for personnel completing claims.
Invariants | ele-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.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(US Core Organization Profile, Organization)
Is Modifier | false
Must Support | true
Summary | true
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.
Invariants | ele-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.
Short | Party 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.
Control | 1..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Invariants | ele-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.
Short | Desired 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.
Control | 0..1
Binding | The codes SHALL be taken from For example codes, see ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority|4.0.1 (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
Invariants | ele-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.
Short | Servicing Facility
Control | 0..1
Type | Reference(US Core Location Profile, Location)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurance adjudication can be dependant on where services were delivered.
Invariants | ele-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.
Short | queued | 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).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes http://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.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-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.
Short | Preauthorization in-effect period
Comments | Prior Authorization in-effect period This value is only present on preauthorization adjudications.
Control | 0..1*
Type | Period
Is Modifier | false
Must Support | true
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-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.
Short | Care Team members
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-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.
Short | Practitioner or organization
Control | 1..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-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.
Short | Patient 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.
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Coverage 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.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-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.
Short | Insurance information
Control | 1..1
Type | Reference(HRex Member Match Coverage Profile, Coverage)
Is Modifier | false
Summary | true
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-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.
Short | Product or service provided
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-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.
Short | ExtensionAdditional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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())
Slicing | This 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 Name | itemTraceNumber
Definition | Uniquely identifies this claim item. (2000F-TRN)
Short | Uniquely identifies this claim item. (2000F-TRN)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | preAuthIssueDate
Definition | The date when this item's preauthorization was issued.
Short | The date when this item's preauthorization was issued.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | preAuthPeriod
Definition | The date/period when this item's preauthorization is valid.
Short | The date/period when this item's preauthorization is valid.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | previousAuthorizationNumber
Definition | A string assigned by the UMO to an authorized review outcome associated with this service item.
Short | A string assigned by the UMO to an authorized review outcome associated with this service item.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(AuthorizationNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | administrationReferenceNumber
Definition | A string assigned by the UMO to the original disallowed review outcome associated with this service item.
Short | A string assigned by the UMO to the original disallowed review outcome associated with this service item.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | authorizedItemDetail
Definition | The details of what has been authorized for this item.
Short | The details of what has been authorized for this item if different from what was requested.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemAuthorizedDetail) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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 Name | authorizedProvider
Definition | The specific provider who has been authorized to provide this item.
Short | The specific provider who has been authorized to provide this item.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(ItemAuthorizedProvider) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-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.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | The codes SHALL be taken from For example codes, see Prior Authorization Service Type Codes (X12)http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1 (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.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-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.
Short | Billing, 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'.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-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.
Short | Encounters related to this billed item
Control | 0..*
Type | Reference(US Core Encounter Profile, Encounter)
Is Modifier | false
Summary | false
Requirements | Used in some jurisdictions to link clinical events to claim items.
Invariants | ele-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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This 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.
Short | ExtensionAdditional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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())
Slicing | This 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 Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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 Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
Slice Name | adjudicationamounttype
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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
96. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
98. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 10..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. ExplanationOfBenefit.item.adjudication:allowedunits
Slice Name | allowedunits
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.
Short | Adjudication details
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. ExplanationOfBenefit.item.adjudication:allowedunits.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
106. ExplanationOfBenefit.item.adjudication:allowedunits.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
108. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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: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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. ExplanationOfBenefit.item.adjudication:allowedunits.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 10..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. ExplanationOfBenefit.item.adjudication:denialreason
Slice Name | denialreason
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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ExplanationOfBenefit.item.adjudication:denialreason.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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:denialreason.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
120. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
122. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. ExplanationOfBenefit.item.adjudication:denialreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. ExplanationOfBenefit.item.adjudication:consumedunits
Slice Name | consumedunits
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.
Short | Adjudication details
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. ExplanationOfBenefit.item.adjudication:consumedunits.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
130. ExplanationOfBenefit.item.adjudication:consumedunits.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
132. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
134. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. ExplanationOfBenefit.item.adjudication:consumedunits.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 10..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. ExplanationOfBenefit.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.adjudication`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: pattern @ category
140. 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.
Short | ExtensionAdditional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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())
Slicing | This 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
142. ExplanationOfBenefit.adjudication.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
144. ExplanationOfBenefit.adjudication.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
146. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
148. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. ExplanationOfBenefit.adjudication:adjudicationamounttype
Slice Name | adjudicationamounttype
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
152. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
154. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
156. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
160. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 10..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. ExplanationOfBenefit.adjudication:denialreason
Slice Name | denialreason
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
164. ExplanationOfBenefit.adjudication:denialreason.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
166. ExplanationOfBenefit.adjudication:denialreason.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
168. ExplanationOfBenefit.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
170. ExplanationOfBenefit.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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PDex Adjudication Category Discriminator http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
172. ExplanationOfBenefit.adjudication:denialreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
174. ExplanationOfBenefit.total
Definition | Categorized monetary totals for the adjudication.
Short | Adjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | To provide the requestor with financial totals by category for the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. 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.
Short | ExtensionAdditional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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())
Slicing | This 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
178. ExplanationOfBenefit.total.extension:priorauth-utilization
Slice Name | priorauth-utilization
Definition | Attribute that expresses the amount of an item or service that has been consumed under the current prior authorization.
Short | An attribute to express the amount of a service or item that has been utilized
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(An attribute to express the amount of a service or item that has been utilized) (Extension Type: Choice of: Quantity, Ratio)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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())
180. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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())
182. 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.
Short | Prior Authorization utilization codesType of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see Prior Authorization value categories http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (extensible to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Needed to convey the type of total provided.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. ExplanationOfBenefit.total.amount
Definition | Monetary total amount associated with the category.
Short | Financial total for the category
Control | 1..1
Type | Money
Is Modifier | false
Summary | true
Requirements | Needed to convey the total monetary amount.
Invariants | ele-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 foundhere

0. ExplanationOfBenefit
Invariants | 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.meta
4. ExplanationOfBenefit.meta.profile
Control | 1..?
Slicing | This 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 Name | supportedProfile
Control | 1..1
Pattern Value | `http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization`
8. ExplanationOfBenefit.extension
Slicing | This 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 Name | levelOfServiceType
Short | A code specifying the level of service being requested (UM06)
Control | 0..1
Type | Extension(LevelOfServiceCode) (Extension Type: CodeableConcept)
Must Support | true
12. ExplanationOfBenefit.status
Must Support | true
14. ExplanationOfBenefit.type
Must Support | true
16. ExplanationOfBenefit.use
Must Support | true
Pattern Value | `preauthorization`
18. ExplanationOfBenefit.patient
Type | Reference(US Core Patient Profile)
Must Support | true
20. ExplanationOfBenefit.enterer
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
22. ExplanationOfBenefit.insurer
Type | Reference(US Core Organization Profile)
Must Support | true
24. ExplanationOfBenefit.provider
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
26. ExplanationOfBenefit.priority
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
28. ExplanationOfBenefit.facility
Type | Reference(US Core Location Profile)
Must Support | true
30. ExplanationOfBenefit.preAuthRefPeriod
Comments | Prior Authorization in-effect period
Control | 0..1
Must Support | true
32. ExplanationOfBenefit.careTeam
34. ExplanationOfBenefit.careTeam.provider
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
36. ExplanationOfBenefit.insurance
38. ExplanationOfBenefit.insurance.coverage
Type | Reference(HRex Member Match Coverage Profile)
40. ExplanationOfBenefit.item
42. ExplanationOfBenefit.item.extension
Slicing | This 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 Name | itemTraceNumber
Short | Uniquely identifies this claim item. (2000F-TRN)
Control | 0..*
Type | Extension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Must Support | true
46. ExplanationOfBenefit.item.extension:preAuthIssueDate
Slice Name | preAuthIssueDate
Short | The date when this item's preauthorization was issued.
Control | 0..1
Type | Extension(ItemPreAuthIssueDate) (Extension Type: date)
Must Support | true
48. ExplanationOfBenefit.item.extension:preAuthPeriod
Slice Name | preAuthPeriod
Short | The date/period when this item's preauthorization is valid.
Control | 0..1
Type | Extension(ItemPreAuthPeriod) (Extension Type: Period)
Must Support | true
50. ExplanationOfBenefit.item.extension:previousAuthorizationNumber
Slice Name | previousAuthorizationNumber
Short | A string assigned by the UMO to an authorized review outcome associated with this service item.
Control | 0..1
Type | Extension(AuthorizationNumber) (Extension Type: string)
Must Support | true
52. ExplanationOfBenefit.item.extension:administrationReferenceNumber
Slice Name | administrationReferenceNumber
Short | A string assigned by the UMO to the original disallowed review outcome associated with this service item.
Control | 0..1
Type | Extension(AdministrationReferenceNumber) (Extension Type: string)
Must Support | true
54. ExplanationOfBenefit.item.extension:authorizedItemDetail
Slice Name | authorizedItemDetail
Short | The details of what has been authorized for this item if different from what was requested.
Control | 0..1
Type | Extension(ItemAuthorizedDetail) (Complex Extension)
Must Support | true
56. ExplanationOfBenefit.item.extension:authorizedProvider
Slice Name | authorizedProvider
Short | The specific provider who has been authorized to provide this item.
Control | 0..*
Type | Extension(ItemAuthorizedProvider) (Complex Extension)
Must Support | true
58. ExplanationOfBenefit.item.category
Binding | The 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 Support | true
60. ExplanationOfBenefit.item.productOrService
Binding | The 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
Type | Reference(US Core Encounter Profile)
64. ExplanationOfBenefit.item.adjudication
Slicing | This 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
Slicing | This 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 Name | reviewAction
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1
Type | Extension(ReviewAction) (Complex Extension)
Must Support | true
70. ExplanationOfBenefit.item.adjudication.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
Short | The date/time when an Adjudication Action occured.
Control | 0..1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Must Support | true
72. ExplanationOfBenefit.item.adjudication.category
Binding | The 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 Name | adjudicationamounttype
Control | 0..*
Must Support | true
76. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category
Binding | The codes SHALL be taken from PDex Adjudication (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
78. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
Control | 1..?
Must Support | true
80. ExplanationOfBenefit.item.adjudication:allowedunits
Slice Name | allowedunits
Control | 0..1
Must Support | true
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
Control | 1..?
Must Support | true
86. ExplanationOfBenefit.item.adjudication:denialreason
Slice Name | denialreason
Control | 0..*
Must Support | true
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
Control | 1..?
Binding | The 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 Support | true
92. ExplanationOfBenefit.item.adjudication:consumedunits
Slice Name | consumedunits
Control | 0..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
Control | 1..?
98. ExplanationOfBenefit.addItem
100. ExplanationOfBenefit.addItem.provider
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
102. ExplanationOfBenefit.adjudication
Type | BackboneElement
Must Support | true
Slicing | This 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
Slicing | This 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 Name | reviewAction
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1
Type | Extension(ReviewAction) (Complex Extension)
Must Support | true
108. ExplanationOfBenefit.adjudication.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
Short | The date/time when an Adjudication Action occured.
Control | 0..1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Must Support | true
110. ExplanationOfBenefit.adjudication.category
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Must Support | true
112. ExplanationOfBenefit.adjudication:adjudicationamounttype
Slice Name | adjudicationamounttype
Control | 0..*
Must Support | true
114. ExplanationOfBenefit.adjudication:adjudicationamounttype.category
Binding | The codes SHALL be taken from PDex Adjudication (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
116. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
Control | 1..?
118. ExplanationOfBenefit.adjudication:denialreason
Slice Name | denialreason
Control | 0..*
Must Support | true
120. ExplanationOfBenefit.adjudication:denialreason.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator", "code" : "denialreason" }] }`
122. ExplanationOfBenefit.adjudication:denialreason.reason
Control | 1..?
Binding | The 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 Support | true
124. ExplanationOfBenefit.total
126. ExplanationOfBenefit.total.extension
Slicing | This 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
128. ExplanationOfBenefit.total.extension:priorauth-utilization
Slice Name | priorauth-utilization
Control | 0..1
Type | Extension(An attribute to express the amount of a service or item that has been utilized) (Extension Type: Choice of: Quantity, Ratio)
Must Support | true
130. ExplanationOfBenefit.total.category
Short | Prior Authorization utilization codes
Binding | Unless not suitable, these codes SHALL be taken from Prior Authorization value categories (extensible to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts` )
Must Support | true

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

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.
Short | Explanation of Benefit resource
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | EOB
Invariants | dom-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.
Short | Logical 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.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
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.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
Slicing | This 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.
Short | Version 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.
Control | 0..1
Type | id
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-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.
Short | When 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.
Control | 0..1
Type | instant
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-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.
Short | Identifies 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.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-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.
Short | Profiles 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.
Control | 1..*
Type | canonical(StructureDefinition)
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This 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 Name | supportedProfile
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.
Short | Profiles 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.
Control | 1..1
Type | canonical(StructureDefinition)
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Pattern Value | `http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization`
Invariants | ele-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.
Short | Security 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.
Control | 0..*
Binding | Unless not suitable, these codes SHALL be taken from All Security Labels (extensible to `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` ) Security Labels from the Healthcare Privacy and Security Classification System.
Type | Coding
Is Modifier | false
Summary | true
Invariants | ele-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.
Short | Tags 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.
Control | 0..*
Binding | For example codes, see CommonTags (example to `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` ) Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
Type | Coding
Is Modifier | false
Summary | true
Invariants | ele-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.
Short | A 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.
Control | 0..1
Type | uri
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-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.
Short | Language 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).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-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.
Short | Text 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.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-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.
Short | Contained, 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.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
32. ExplanationOfBenefit.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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 Name | levelOfServiceType
Definition | A code specifying the level of service being requested (UM06)
Short | A code specifying the level of service being requested (UM06)
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(LevelOfServiceCode) (Extension Type: CodeableConcept)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
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 Names | extensions, user content
Invariants | ele-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.
Short | Business Identifier for the resource
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows EOBs to be distinguished and referenced.
Invariants | ele-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.
Short | active | 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.
Control | 1..1
Binding | The 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.
Type | code
Is Modifier | true 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 Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
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'.
Invariants | ele-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.
Short | Category 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.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Invariants | ele-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.
Short | More granular claim type
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Control | 0..1
Binding | For example codes, see ExampleClaimSubTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` ) A more granular claim typecode.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-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.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Complete, proposed, exploratory, other.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Pattern Value | `preauthorization`
Invariants | ele-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.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile)
Is Modifier | false
Must Support | true
Summary | true
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.
Invariants | ele-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.
Short | Relevant 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.
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
Invariants | ele-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.
Short | Response 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.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-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.
Short | Author of the claim
Control | 0..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Some jurisdictions require the contact information for personnel completing claims.
Invariants | ele-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.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(US Core Organization Profile)
Is Modifier | false
Must Support | true
Summary | true
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.
Invariants | ele-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.
Short | Party 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.
Control | 1..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Invariants | ele-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.
Short | Desired 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.
Control | 0..1
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
Invariants | ele-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.
Short | For whom to reserve funds
Comments | This field is only used for preauthorizations.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
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 Names | Fund pre-allocation
Invariants | ele-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.
Short | Funds reserved status
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Invariants | ele-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.
Short | Prior or corollary claims
Comments | For example, for the original treatment and follow-up exams.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Reference to the related claim
Control | 0..1
Type | Reference(Claim)
Is Modifier | false
Summary | false
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Invariants | ele-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.
Short | How the reference claim is related
Comments | For example, prior claim or umbrella.
Control | 0..1
Binding | For example codes, see ExampleRelatedClaimRelationshipCodes (example to `http://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1` ) Relationship of this claim to a related Claim.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some insurers need a declaration of the type of relationship.
Invariants | ele-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.
Short | File or case reference
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number.
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
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.
Invariants | ele-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.
Short | Prescription authorizing services or products
Control | 0..1
Type | Reference(MedicationRequest, VisionPrescription)
Is Modifier | false
Summary | false
Requirements | Required to authorize the dispensing of controlled substances and devices.
Invariants | ele-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.
Short | Original 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'.
Control | 0..1
Type | Reference(MedicationRequest)
Is Modifier | false
Summary | false
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
Invariants | ele-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.
Short | Recipient 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.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Category of recipient
Control | 0..1
Binding | For example codes, see Claim Payee Type Codes (example to `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-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.
Short | Recipient reference
Comments | Not required if the payee is 'subscriber' or 'provider'.
Control | 0..1
Type | Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
Is Modifier | false
Summary | false
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
Invariants | ele-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.
Short | Treatment Referral
Comments | The referral resource which lists the date, practitioner, reason and other supporting information.
Control | 0..1
Type | Reference(ServiceRequest)
Is Modifier | false
Summary | false
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services.
Invariants | ele-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.
Short | Servicing Facility
Control | 0..1
Type | Reference(US Core Location Profile)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurance adjudication can be dependant on where services were delivered.
Invariants | ele-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.
Short | Claim reference
Control | 0..1
Type | Reference(Claim)
Is Modifier | false
Summary | false
Requirements | To provide a link to the original adjudication request.
Invariants | ele-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.
Short | Claim response reference
Control | 0..1
Type | Reference(ClaimResponse)
Is Modifier | false
Summary | false
Requirements | To provide a link to the original adjudication response.
Invariants | ele-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.
Short | queued | 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).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-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.
Short | Disposition Message
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provided for user display.
Invariants | ele-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.
Short | Preauthorization reference
Comments | This value is only present on preauthorization adjudications.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-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.
Short | Preauthorization in-effect period
Comments | Prior Authorization in-effect period
Control | 0..1
Type | Period
Is Modifier | false
Must Support | true
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-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.
Short | Care Team members
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-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.
Short | Practitioner or organization
Control | 1..1
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
Is Modifier | false
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-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.
Short | Indicator of the lead practitioner
Comments | Responsible might not be required when there is only a single provider listed.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Invariants | ele-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.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 0..1
Binding | For example codes, see ClaimCareTeamRoleCodes (example to `http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1` ) The role codes for the care team members.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Invariants | ele-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.
Short | Practitioner credential or specialization
Control | 0..1
Binding | For example codes, see ExampleProviderQualificationCodes (example to `http://hl7.org/fhir/ValueSet/provider-qualification|4.0.1` ) Provider professional qualifications.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-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.
Short | Supporting information
Comments | Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-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.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | For example codes, see ClaimInformationCategoryCodes (example to `http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1` ) The valuset used for additional information category codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Invariants | ele-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.
Short | Type of information
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Control | 0..1
Binding | For example codes, see ExceptionCodes (example to `http://hl7.org/fhir/ValueSet/claim-exception|4.0.1` ) The valuset used for additional information codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-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.
Short | When it occurred
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-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.
Short | Data 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.
Control | 0..1
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-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.
Short | Explanation for the information
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes (example to `http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1` ) Reason codes for the missing teeth.
Type | Coding
Is Modifier | false
Summary | false
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Invariants | ele-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.
Short | Pertinent diagnosis information
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-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.
Short | Nature of illness or problem
Control | 1..1
Binding | For example codes, see ICD-10Codes (example to `http://hl7.org/fhir/ValueSet/icd-10|4.0.1` ) ICD10 Diagnostic codes.
Type | Choice of: CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-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.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 0..*
Binding | For example codes, see ExampleDiagnosisTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1` ) The type of the diagnosis: admitting, principal, discharge.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-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.
Short | Present on admission
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1` ) Present on admission.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | ele-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.
Short | Package 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.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1` ) The DRG codes associated with the diagnosis.
Type | CodeableConcept
Is Modifier | false
Summary | false
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.
Invariants | ele-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.
Short | Clinical procedures performed
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-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.
Short | Category of Procedure
Control | 0..*
Binding | For example codes, see ExampleProcedureTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1` ) Example procedure type codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-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.
Short | When the procedure was performed
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for auditing purposes.
Invariants | ele-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.
Short | Specific clinical procedure
Control | 1..1
Binding | For example codes, see ICD-10ProcedureCodes (example to `http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1` ) ICD10 Procedure codes.
Type | Choice of: CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-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.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-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.
Short | Precedence (primary, secondary, etc.)
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to coordinate between multiple EOBs for the same suite of services.
Invariants | ele-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.
Short | Patient 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.
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Coverage 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.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-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.
Short | Insurance information
Control | 1..1
Type | Reference(HRex Member Match Coverage Profile)
Is Modifier | false
Summary | true
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-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.
Short | Prior 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.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Invariants | ele-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.
Short | Details of the event
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
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.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | When the incident occurred
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for audit purposes and adjudication.
Invariants | ele-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.
Short | The nature of the accident
Control | 0..1
Binding | Unless 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.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Coverage may be dependant on the type of accident.
Invariants | ele-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.
Short | Where the event occurred
Control | 0..1
Type | Choice of: Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Required for audit purposes and determination of applicable insurance liability.
Invariants | ele-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.
Short | Product or service provided
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
220. ExplanationOfBenefit.item.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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 Name | itemTraceNumber
Definition | Uniquely identifies this claim item. (2000F-TRN)
Short | Uniquely identifies this claim item. (2000F-TRN)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | preAuthIssueDate
Definition | The date when this item's preauthorization was issued.
Short | The date when this item's preauthorization was issued.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | preAuthPeriod
Definition | The date/period when this item's preauthorization is valid.
Short | The date/period when this item's preauthorization is valid.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | previousAuthorizationNumber
Definition | A string assigned by the UMO to an authorized review outcome associated with this service item.
Short | A string assigned by the UMO to an authorized review outcome associated with this service item.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(AuthorizationNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | administrationReferenceNumber
Definition | A string assigned by the UMO to the original disallowed review outcome associated with this service item.
Short | A string assigned by the UMO to the original disallowed review outcome associated with this service item.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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 Name | authorizedItemDetail
Definition | The details of what has been authorized for this item.
Short | The details of what has been authorized for this item if different from what was requested.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ItemAuthorizedDetail) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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 Name | authorizedProvider
Definition | The specific provider who has been authorized to provide this item.
Short | The specific provider who has been authorized to provide this item.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(ItemAuthorizedProvider) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-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.
Short | Applicable care team members
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to identify the individuals and their roles in the provision of the product or service.
Invariants | ele-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.
Short | Applicable diagnoses
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to related the product or service to the associated diagnoses.
Invariants | ele-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.
Short | Applicable procedures
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to provide any listed specific procedures to support the product or service being claimed.
Invariants | ele-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.
Short | Applicable exception and supporting information
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to reference the supporting information items that relate directly to this product or service.
Invariants | ele-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.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-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.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | The 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.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-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.
Short | Billing, 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'.
Control | 1..1
Binding | The 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` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-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.
Short | Product 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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-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.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-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.
Short | Date or dates of service or product delivery
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-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.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place|4.0.1` ) Place where the service is rendered.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-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.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-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.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-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.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-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.).
Short | Anatomical 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.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-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).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-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.
Short | Encounters related to this billed item
Control | 0..*
Type | Reference(US Core Encounter Profile)
Is Modifier | false
Summary | false
Requirements | Used in some jurisdictions to link clinical events to claim items.
Invariants | ele-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.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
284. ExplanationOfBenefit.item.adjudication.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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 Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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 Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-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.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-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.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-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.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
300. ExplanationOfBenefit.item.adjudication:adjudicationamounttype
Slice Name | adjudicationamounttype
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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
304. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
306. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
310. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
312. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
314. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
316. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 1..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
318. ExplanationOfBenefit.item.adjudication:adjudicationamounttype.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
320. ExplanationOfBenefit.item.adjudication:allowedunits
Slice Name | allowedunits
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.
Short | Adjudication details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
322. 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
324. ExplanationOfBenefit.item.adjudication:allowedunits.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
326. ExplanationOfBenefit.item.adjudication:allowedunits.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
328. ExplanationOfBenefit.item.adjudication:allowedunits.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
330. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
332. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
334. ExplanationOfBenefit.item.adjudication:allowedunits.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
336. ExplanationOfBenefit.item.adjudication:allowedunits.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
338. ExplanationOfBenefit.item.adjudication:allowedunits.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 1..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
340. ExplanationOfBenefit.item.adjudication:denialreason
Slice Name | denialreason
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.
Short | Adjudication details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
342. 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
344. ExplanationOfBenefit.item.adjudication:denialreason.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
346. ExplanationOfBenefit.item.adjudication:denialreason.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
348. ExplanationOfBenefit.item.adjudication:denialreason.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
350. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
352. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
354. ExplanationOfBenefit.item.adjudication:denialreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 1..1
Binding | The 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` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
356. ExplanationOfBenefit.item.adjudication:denialreason.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
358. ExplanationOfBenefit.item.adjudication:denialreason.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
360. ExplanationOfBenefit.item.adjudication:consumedunits
Slice Name | consumedunits
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.
Short | Adjudication details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
362. 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
364. ExplanationOfBenefit.item.adjudication:consumedunits.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
366. ExplanationOfBenefit.item.adjudication:consumedunits.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization at the line level.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
368. ExplanationOfBenefit.item.adjudication:consumedunits.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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.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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
374. ExplanationOfBenefit.item.adjudication:consumedunits.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
376. ExplanationOfBenefit.item.adjudication:consumedunits.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
378. ExplanationOfBenefit.item.adjudication:consumedunits.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 1..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
380. ExplanationOfBenefit.item.detail
Definition | Second-tier of goods and services.
Short | Additional items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
382. 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
384. 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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
386. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
388. 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.
Short | Product or service provided
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
390. ExplanationOfBenefit.item.detail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
392. ExplanationOfBenefit.item.detail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
394. 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.
Short | Billing, 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'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
396. ExplanationOfBenefit.item.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
398. ExplanationOfBenefit.item.detail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
400. ExplanationOfBenefit.item.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
402. 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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
404. 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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
406. ExplanationOfBenefit.item.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
408. ExplanationOfBenefit.item.detail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
410. ExplanationOfBenefit.item.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
412. ExplanationOfBenefit.item.detail.adjudication
Definition | The adjudication results.
Short | Detail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
414. ExplanationOfBenefit.item.detail.subDetail
Definition | Third-tier of goods and services.
Short | Additional items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
416. 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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
418. 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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
420. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
422. 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.
Short | Product or service provided
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
424. ExplanationOfBenefit.item.detail.subDetail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
426. ExplanationOfBenefit.item.detail.subDetail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
428. 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.
Short | Billing, 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'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
430. ExplanationOfBenefit.item.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
432. ExplanationOfBenefit.item.detail.subDetail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
434. ExplanationOfBenefit.item.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
436. ExplanationOfBenefit.item.detail.subDetail.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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
438. ExplanationOfBenefit.item.detail.subDetail.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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
440. ExplanationOfBenefit.item.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
442. ExplanationOfBenefit.item.detail.subDetail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
444. ExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
446. ExplanationOfBenefit.item.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Subdetail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
448. ExplanationOfBenefit.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
450. ExplanationOfBenefit.addItem.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
452. ExplanationOfBenefit.addItem.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
454. ExplanationOfBenefit.addItem.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
456. ExplanationOfBenefit.addItem.itemSequence
Definition | Claim items which this service line is intended to replace.
Short | Item sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
458. ExplanationOfBenefit.addItem.detailSequence
Definition | The sequence number of the details within the claim item which this line is intended to replace.
Short | Detail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
460. ExplanationOfBenefit.addItem.subDetailSequence
Definition | The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
Short | Subdetail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
462. ExplanationOfBenefit.addItem.provider
Definition | The providers who are authorized for the services rendered to the patient.
Short | Authorized providers
Control | 0..*
Type | Reference(US Core Practitioner Profile, US Core PractitionerRole Profile, US Core Organization Profile)
Is Modifier | false
Summary | false
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
464. ExplanationOfBenefit.addItem.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.
Short | Billing, 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'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
466. ExplanationOfBenefit.addItem.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
468. ExplanationOfBenefit.addItem.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
470. ExplanationOfBenefit.addItem.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Short | Date or dates of service or product delivery
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
472. ExplanationOfBenefit.addItem.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place|4.0.1` ) Place where the service is rendered.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
474. ExplanationOfBenefit.addItem.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
476. ExplanationOfBenefit.addItem.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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
478. ExplanationOfBenefit.addItem.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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
480. ExplanationOfBenefit.addItem.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
482. ExplanationOfBenefit.addItem.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical 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.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
484. ExplanationOfBenefit.addItem.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
486. ExplanationOfBenefit.addItem.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
488. ExplanationOfBenefit.addItem.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
490. ExplanationOfBenefit.addItem.detail
Definition | The second-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
492. ExplanationOfBenefit.addItem.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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
494. ExplanationOfBenefit.addItem.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
496. ExplanationOfBenefit.addItem.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
498. ExplanationOfBenefit.addItem.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.
Short | Billing, 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'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
500. ExplanationOfBenefit.addItem.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
502. ExplanationOfBenefit.addItem.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
504. ExplanationOfBenefit.addItem.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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
506. ExplanationOfBenefit.addItem.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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
508. ExplanationOfBenefit.addItem.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
510. ExplanationOfBenefit.addItem.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
512. ExplanationOfBenefit.addItem.detail.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
514. ExplanationOfBenefit.addItem.detail.subDetail
Definition | The third-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
516. ExplanationOfBenefit.addItem.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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
518. ExplanationOfBenefit.addItem.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
520. ExplanationOfBenefit.addItem.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
522. ExplanationOfBenefit.addItem.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.
Short | Billing, 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'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
524. ExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/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.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
526. ExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
528. ExplanationOfBenefit.addItem.detail.subDetail.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.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
530. ExplanationOfBenefit.addItem.detail.subDetail.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.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
532. ExplanationOfBenefit.addItem.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
534. ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
536. ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
538. ExplanationOfBenefit.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.adjudication`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: pattern @ category
540. ExplanationOfBenefit.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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
542. ExplanationOfBenefit.adjudication.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
544. ExplanationOfBenefit.adjudication.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
546. ExplanationOfBenefit.adjudication.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
548. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
550. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
552. ExplanationOfBenefit.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
554. ExplanationOfBenefit.adjudication.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
556. ExplanationOfBenefit.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
558. ExplanationOfBenefit.adjudication:adjudicationamounttype
Slice Name | adjudicationamounttype
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
560. ExplanationOfBenefit.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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
562. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
564. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
566. ExplanationOfBenefit.adjudication:adjudicationamounttype.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
568. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
570. 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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
572. ExplanationOfBenefit.adjudication:adjudicationamounttype.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
574. ExplanationOfBenefit.adjudication:adjudicationamounttype.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
576. ExplanationOfBenefit.adjudication:adjudicationamounttype.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
578. ExplanationOfBenefit.adjudication:denialreason
Slice Name | denialreason
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
580. ExplanationOfBenefit.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.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
582. ExplanationOfBenefit.adjudication:denialreason.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
584. ExplanationOfBenefit.adjudication:denialreason.extension:reviewAction
Slice Name | reviewAction
Definition | The details of the review action that is necessary for the authorization.
Short | The details of the review action that is necessary for the authorization for the entire request.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ReviewAction) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-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()`)
586. ExplanationOfBenefit.adjudication:denialreason.extension:adjudicationActionDate
Slice Name | adjudicationActionDate
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.
Short | The date/time when an Adjudication Action occured.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(When Adjudicated) (Extension Type: dateTime)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
588. ExplanationOfBenefit.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
590. ExplanationOfBenefit.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.
Short | Type of adjudication information
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from PDex Adjudication Category Discriminator (required to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
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" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
592. ExplanationOfBenefit.adjudication:denialreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 1..1
Binding | The 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` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
594. ExplanationOfBenefit.adjudication:denialreason.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
596. ExplanationOfBenefit.adjudication:denialreason.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
598. ExplanationOfBenefit.total
Definition | Categorized monetary totals for the adjudication.
Short | Adjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | To provide the requestor with financial totals by category for the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
600. ExplanationOfBenefit.total.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
602. ExplanationOfBenefit.total.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-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()`)
Slicing | This 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
604. ExplanationOfBenefit.total.extension:priorauth-utilization
Slice Name | priorauth-utilization
Definition | Attribute that expresses the amount of an item or service that has been consumed under the current prior authorization.
Short | An attribute to express the amount of a service or item that has been utilized
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(An attribute to express the amount of a service or item that has been utilized) (Extension Type: Choice of: Quantity, Ratio)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-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()`)
606. 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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
608. 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.
Short | Prior Authorization utilization codes
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from Prior Authorization value categories (extensible to `http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Needed to convey the type of total provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
610. ExplanationOfBenefit.total.amount
Definition | Monetary total amount associated with the category.
Short | Financial total for the category
Control | 1..1
Type | Money
Is Modifier | false
Summary | true
Requirements | Needed to convey the total monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
612. ExplanationOfBenefit.payment
Definition | Payment details for the adjudication of the claim.
Short | Payment Details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
614. ExplanationOfBenefit.payment.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
616. ExplanationOfBenefit.payment.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
618. ExplanationOfBenefit.payment.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
620. ExplanationOfBenefit.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Short | Partial or complete payment
Control | 0..1
Binding | For example codes, see ExamplePaymentTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1` ) The type (partial, complete) of the payment.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
622. ExplanationOfBenefit.payment.adjustment
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Short | Payment adjustment for non-claim issues
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | To advise the requestor of adjustments applied to the payment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
624. ExplanationOfBenefit.payment.adjustmentReason
Definition | Reason for the payment adjustment.
Short | Explanation for the variance
Control | 0..1
Binding | For example codes, see PaymentAdjustmentReasonCodes (example to `http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1` ) Payment Adjustment reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to clarify the monetary adjustment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
626. ExplanationOfBenefit.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Short | Expected date of payment
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To advise the payee when payment can be expected.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
628. ExplanationOfBenefit.payment.amount
Definition | Benefits payable less any payment adjustment.
Short | Payable amount after adjustment
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Needed to provide the actual payment amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
630. ExplanationOfBenefit.payment.identifier
Definition | Issuer's unique identifier for the payment instrument.
Short | Business identifier for the payment
Comments | For example: EFT number or check number.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Enable the receiver to reconcile when payment received.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
632. ExplanationOfBenefit.formCode
Definition | A code for the form to be used for printing the content.
Short | Printed form identifier
Comments | May be needed to identify specific jurisdictional forms.
Control | 0..1
Binding | For example codes, see Form Codes (example to `http://hl7.org/fhir/ValueSet/forms|4.0.1` ) The forms codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to specify the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
634. ExplanationOfBenefit.form
Definition | The actual form, by reference or inclusion, for printing the content or an EOB.
Short | Printed reference or actual form
Comments | Needed to permit insurers to include the actual form.
Control | 0..1
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Needed to include the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
636. ExplanationOfBenefit.processNote
Definition | A note that describes or explains adjudication results in a human readable form.
Short | Note concerning adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Provides the insurer specific textual explanations associated with the processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
638. ExplanationOfBenefit.processNote.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
640. ExplanationOfBenefit.processNote.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
642. ExplanationOfBenefit.processNote.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
644. ExplanationOfBenefit.processNote.number
Definition | A number to uniquely identify a note entry.
Short | Note instance identifier
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link from adjudications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
646. ExplanationOfBenefit.processNote.type
Definition | The business purpose of the note text.
Short | display | print | printoper
Control | 0..1
Binding | The codes SHALL be taken from NoteType (required to `http://hl7.org/fhir/ValueSet/note-type|4.0.1` ) The presentation types of notes.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the expectation for when the text is used.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
648. ExplanationOfBenefit.processNote.text
Definition | The explanation or description associated with the processing.
Short | Note explanatory text
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required to provide human readable explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
650. ExplanationOfBenefit.processNote.language
Definition | A code to define the language used in the text of the note.
Short | Language of the text
Comments | Only required if the language is different from the resource language.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Note text may vary from the resource defined language.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
652. ExplanationOfBenefit.benefitPeriod
Definition | The term of the benefits documented in this response.
Short | When the benefits are applicable
Comments | Not applicable when use=claim.
Control | 0..1
Type | Period
Is Modifier | false
Summary | false
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
654. ExplanationOfBenefit.benefitBalance
Definition | Balance by Benefit Category.
Short | Balance by Benefit Category
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
656. ExplanationOfBenefit.benefitBalance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
658. ExplanationOfBenefit.benefitBalance.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
660. ExplanationOfBenefit.benefitBalance.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
662. ExplanationOfBenefit.benefitBalance.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 1..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to convey the category of service or product for which eligibility is sought.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
664. ExplanationOfBenefit.benefitBalance.excluded
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Short | Excluded from the plan
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to identify items that are specifically excluded from the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
666. ExplanationOfBenefit.benefitBalance.name
Definition | A short name or tag for the benefit.
Short | Short name for the benefit
Comments | For example: MED01, or DENT2.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required to align with other plan names.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
668. ExplanationOfBenefit.benefitBalance.description
Definition | A richer description of the benefit or services covered.
Short | Description of the benefit or services covered
Comments | For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed for human readable reference.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
670. ExplanationOfBenefit.benefitBalance.network
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Short | In or out of network
Control | 0..1
Binding | For example codes, see NetworkTypeCodes (example to `http://hl7.org/fhir/ValueSet/benefit-network|4.0.1` ) Code to classify in or out of network services.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed as in or out of network providers are treated differently under the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
672. ExplanationOfBenefit.benefitBalance.unit
Definition | Indicates if the benefits apply to an individual or to the family.
Short | Individual or family
Control | 0..1
Binding | For example codes, see UnitTypeCodes (example to `http://hl7.org/fhir/ValueSet/benefit-unit|4.0.1` ) Unit covered/serviced - individual or family.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed for the understanding of the benefits.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
674. ExplanationOfBenefit.benefitBalance.term
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
Short | Annual or lifetime
Control | 0..1
Binding | For example codes, see BenefitTermCodes (example to `http://hl7.org/fhir/ValueSet/benefit-term|4.0.1` ) Coverage unit - annual, lifetime.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed for the understanding of the benefits.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
676. ExplanationOfBenefit.benefitBalance.financial
Definition | Benefits Used to date.
Short | Benefit Summary
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
678. ExplanationOfBenefit.benefitBalance.financial.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
680. ExplanationOfBenefit.benefitBalance.financial.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.
Short | Additional 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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-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()`)
682. ExplanationOfBenefit.benefitBalance.financial.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).
Short | Extensions 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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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 Names | extensions, user content, modifiers
Invariants | ele-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()`)
684. ExplanationOfBenefit.benefitBalance.financial.type
Definition | Classification of benefit being provided.
Short | Benefit classification
Comments | For example: deductible, visits, benefit amount.
Control | 1..1
Binding | For example codes, see BenefitTypeCodes (example to `http://hl7.org/fhir/ValueSet/benefit-type|4.0.1` ) Deductable, visits, co-pay, etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to convey the nature of the benefit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
686. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 0..1
Type | Choice of: unsignedInt, string, Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to convey the benefits offered under the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
688. ExplanationOfBenefit.benefitBalance.financial.used[x]
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 0..1
Type | Choice of: unsignedInt, Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to convey the benefits consumed to date.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)