Profile Comparison between http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization vs http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
copyright	Used by permission of HL7 International, all rights reserved Creative Commons License
date	2024-08-14T20:04:35+00:00	2024-11-20T18:18:31+00:00	Values Differ
description	The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members.
experimental	false
fhirVersion	4.0.1
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	resource
name	PdexPriorAuthorization
publisher	HL7 International / Financial Management
purpose
status	active
title	PDex Prior Authorization
type	ExplanationOfBenefit
url	http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
version	2.1.0-ballot	2.1.1	Values Differ

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	R Type	R Description & Constraints	Comments
ExplanationOfBenefit	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
id	Σ	0..1	id	Logical id of this artifact	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from	Σ	0..1	uri	Identifies where the resource comes from
Slices for profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: ?? (extensible): Security Labels from the Healthcare Privacy and Security Classification System.	Σ	0..*	Coding	Security Labels applied to this resource Binding: ?? (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: ?? (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".	Σ	0..*	Coding	Tags applied to this resource Binding: ?? (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for the resource		0..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance.	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ?? (extensible): The type or discipline-style of the claim.	SΣ	1..1	CodeableConcept	Category or discipline Binding: ?? (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ?? (example): A more granular claim typecode.		0..1	CodeableConcept	More granular claim type Binding: ?? (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: ?? (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization	SΣ	1..1	code	claim | preauthorization | predetermination Binding: ?? (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services	SΣ	1..1	Reference(US Core Patient Profile(7.0.0))	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Response creation date	Σ	1..1	dateTime	Response creation date
enterer	S	0..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0))	Author of the claim	S	0..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0))	Author of the claim
insurer	SΣ	1..1	Reference(US Core Organization Profile(7.0.0))	Party responsible for reimbursement	SΣ	1..1	Reference(US Core Organization Profile(7.0.0))	Party responsible for reimbursement
provider	SΣ	1..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Party responsible for the claim	SΣ	1..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ?? (required)		0..1	CodeableConcept	Desired processing urgency Binding: ?? (required)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).		0..1	CodeableConcept	For whom to reserve funds Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).		0..1	CodeableConcept	Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ?? (example): Relationship of this claim to a related Claim.		0..1	CodeableConcept	How the reference claim is related Binding: ?? (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(MedicationRequest | VisionPrescription)	Prescription authorizing services or products		0..1	Reference(MedicationRequest | VisionPrescription)	Prescription authorizing services or products
originalPrescription		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Category of recipient Binding: ?? (example): A code for the party to be reimbursed.		0..1	CodeableConcept	Category of recipient Binding: ?? (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment Referral		0..1	Reference(ServiceRequest)	Treatment Referral
facility	S	0..1	Reference(US Core Location Profile(7.0.0))	Servicing Facility	S	0..1	Reference(US Core Location Profile(7.0.0))	Servicing Facility
claim		0..1	Reference(Claim)	Claim reference		0..1	Reference(Claim)	Claim reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference		0..1	Reference(ClaimResponse)	Claim response reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ?? (required): The result of the claim processing.	Σ	1..1	code	queued | complete | error | partial Binding: ?? (required): The result of the claim processing.
disposition		0..1	string	Disposition Message		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference		0..*	string	Preauthorization reference
preAuthRefPeriod	S	0..1	Period	Preauthorization in-effect period	S	0..1	Period	Preauthorization in-effect period
careTeam		0..*	BackboneElement	Care Team members		0..*	BackboneElement	Care Team members
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Practitioner or organization	S	1..1	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ?? (example): The role codes for the care team members.		0..1	CodeableConcept	Function within the team Binding: ?? (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ?? (example): Provider professional qualifications.		0..1	CodeableConcept	Practitioner credential or specialization Binding: ?? (example): Provider professional qualifications.
supportingInfo		0..*	BackboneElement	Supporting information		0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ?? (example): The valuset used for additional information category codes.		1..1	CodeableConcept	Classification of the supplied information Binding: ?? (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ?? (example): The valuset used for additional information codes.		0..1	CodeableConcept	Type of information Binding: ?? (example): The valuset used for additional information codes.
timing[x]		0..1	date, Period	When it occurred		0..1	date, Period	When it occurred
value[x]		0..1	boolean, string, Quantity, Attachment, Reference(Resource)	Data to be provided		0..1	boolean, string, Quantity, Attachment, Reference(Resource)	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: ?? (example): Reason codes for the missing teeth.		0..1	Coding	Explanation for the information Binding: ?? (example): Reason codes for the missing teeth.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1	CodeableConcept, Reference(Condition)	Nature of illness or problem Binding: ?? (example): ICD10 Diagnostic codes.		1..1	CodeableConcept, Reference(Condition)	Nature of illness or problem Binding: ?? (example): ICD10 Diagnostic codes.
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ?? (example): The type of the diagnosis: admitting, principal, discharge.		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ?? (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ?? (example): Present on admission.		0..1	CodeableConcept	Present on admission Binding: ?? (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ?? (example): The DRG codes associated with the diagnosis.		0..1	CodeableConcept	Package billing code Binding: ?? (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ?? (example): Example procedure type codes.		0..*	CodeableConcept	Category of Procedure Binding: ?? (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed		0..1	dateTime	When the procedure was performed
procedure[x]		1..1	CodeableConcept, Reference(Procedure)	Specific clinical procedure Binding: ?? (example): ICD10 Procedure codes.		1..1	CodeableConcept, Reference(Procedure)	Specific clinical procedure Binding: ?? (example): ICD10 Procedure codes.
udi		0..*	Reference(Device)	Unique device identifier		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	Σ	1..*	BackboneElement	Patient insurance information	Σ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	Σ	1..1	boolean	Coverage to be used for adjudication	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(HRex Member Match Coverage Profile(1.1.0))	Insurance information	Σ	1..1	Reference(HRex Member Match Coverage Profile(1.1.0))	Insurance information
preAuthRef		0..*	string	Prior authorization reference number		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ?? (extensible): Type of accident: work place, auto, etc.		0..1	CodeableConcept	The nature of the accident Binding: ?? (extensible): Type of accident: work place, auto, etc.
location[x]		0..1	Address, Reference(Location)	Where the event occurred		0..1	Address, Reference(Location)	Where the event occurred
item		0..*	BackboneElement	Product or service provided		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier		1..1	positiveInt	Item instance identifier
careTeamSequence		0..*	positiveInt	Applicable care team members		0..*	positiveInt	Applicable care team members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
category	S	0..1	CodeableConcept	Benefit classification Binding: ?? (required): 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.	S	0..1	CodeableConcept	Benefit classification Binding: ?? (required): 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.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (required)		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Product or service billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
serviced[x]		0..1	date, Period	Date or dates of service or product delivery		0..1	date, Period	Date or dates of service or product delivery
location[x]		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: ?? (example): Place where the service is rendered.		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: ?? (example): Place where the service is rendered.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.		0..1	CodeableConcept	Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations.		0..*	CodeableConcept	Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(US Core Encounter Profile(7.0.0))	Encounters related to this billed item		0..*	Reference(US Core Encounter Profile(7.0.0))	Encounters related to this billed item
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
Slices for adjudication		0..*	BackboneElement	Adjudication details Slice: Unordered, Closed by pattern:category		0..*	BackboneElement	Adjudication details Slice: Unordered, Closed by pattern:category
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: ?? (required)		1..1	CodeableConcept	Type of adjudication information Binding: ?? (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: ?? (example): Adjudication reason codes.		0..1	CodeableConcept	Explanation of adjudication outcome Binding: ?? (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value		0..1	decimal	Non-monitary value
detail		0..*	BackboneElement	Additional items		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details
subDetail		0..*	BackboneElement	Additional items		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number		0..*	positiveInt	Detail sequence number
subDetailSequence		0..*	positiveInt	Subdetail sequence number		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Authorized providers		0..*	Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
serviced[x]		0..1	date, Period	Date or dates of service or product delivery		0..1	date, Period	Date or dates of service or product delivery
location[x]		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: ?? (example): Place where the service is rendered.		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: ?? (example): Place where the service is rendered.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.		0..1	CodeableConcept	Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations.		0..*	CodeableConcept	Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line items		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
subDetail		0..*	BackboneElement	Insurer added line items		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	??	Count of products or services		0..1	??	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
Slices for adjudication	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Closed by pattern:category	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Closed by pattern:category
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: ?? (required)	S	1..1	CodeableConcept	Type of adjudication information Binding: ?? (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: ?? (example): Adjudication reason codes.		0..1	CodeableConcept	Explanation of adjudication outcome Binding: ?? (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value		0..1	decimal	Non-monitary value
total	Σ	0..*	BackboneElement	Adjudication totals	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Prior Authorization utilization codes Binding: ?? (extensible)	SΣ	1..1	CodeableConcept	Prior Authorization utilization codes Binding: ?? (extensible)
amount	Σ	1..1	Money	Financial total for the category	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment.		0..1	CodeableConcept	Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: ?? (example): Payment Adjustment reason codes.		0..1	CodeableConcept	Explanation for the variance Binding: ?? (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment		0..1	date	Expected date of payment
amount		0..1	Money	Payable amount after adjustment		0..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment		0..1	Identifier	Business identifier for the payment
formCode		0..1	CodeableConcept	Printed form identifier Binding: ?? (example): The forms codes.		0..1	CodeableConcept	Printed form identifier Binding: ?? (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: ?? (required): The presentation types of notes.		0..1	code	display | print | printoper Binding: ?? (required): The presentation types of notes.
text		0..1	string	Note explanatory text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding		0..1	CodeableConcept	Language of the text Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding
benefitPeriod		0..1	Period	When the benefits are applicable		0..1	Period	When the benefits are applicable
benefitBalance		0..*	BackboneElement	Balance by Benefit Category		0..*	BackboneElement	Balance by Benefit Category
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.		1..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded		0..1	boolean	Excluded from the plan		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: ?? (example): Code to classify in or out of network services.		0..1	CodeableConcept	In or out of network Binding: ?? (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: ?? (example): Unit covered/serviced - individual or family.		0..1	CodeableConcept	Individual or family Binding: ?? (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: ?? (example): Coverage unit - annual, lifetime.		0..1	CodeableConcept	Annual or lifetime Binding: ?? (example): Coverage unit - annual, lifetime.
financial		0..*	BackboneElement	Benefit Summary		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: ?? (example): Deductable, visits, co-pay, etc.		1..1	CodeableConcept	Benefit classification Binding: ?? (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1	unsignedInt, string, Money	Benefits allowed		0..1	unsignedInt, string, Money	Benefits allowed
used[x]		0..1	unsignedInt, Money	Benefits used		0..1	unsignedInt, Money	Benefits used
Documentation for this format