Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Resource Profile: PCTAdvancedEOB - Detailed Descriptions

Page standards status: Trial-use Maturity Level: 2

Definitions for the davinci-pct-aeob resource profile.

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

0. ExplanationOfBenefit
Invariantspct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists())
pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists())
pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists())
2. ExplanationOfBenefit.extension
Control1..?
SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 4. ExplanationOfBenefit.extension:gfeReference
    Slice NamegfeReference
    ShortThe GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
    Control1..*
    TypeExtension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle))
    6. ExplanationOfBenefit.extension:serviceDescription
    Slice NameserviceDescription
    Control0..1
    This element is affected by the following invariants: pct-aeob-1
    TypeExtension(Service Description) (Extension Type: string)
    Must Supporttrue
    8. ExplanationOfBenefit.extension:outOfNetworkProviderInfo
    Slice NameoutOfNetworkProviderInfo
    Control0..1
    TypeExtension(In Network Provider Options Link) (Extension Type: url)
    Must Supporttrue
    10. ExplanationOfBenefit.identifier
    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control1..?
    SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
    • pattern @ type
    • 12. ExplanationOfBenefit.identifier:INTER
      Slice NameINTER
      ShortIntermediary System Identifier
      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      14. ExplanationOfBenefit.identifier:INTER.type
      Control1..?
      Pattern Value{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
          "code" : "INTER",
          "display" : "Intermediary System Identifier"
        }]
      }
      16. ExplanationOfBenefit.identifier:uniqueclaimid
      Slice Nameuniqueclaimid
      ShortUnique Claim ID
      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control1..1
      18. ExplanationOfBenefit.identifier:uniqueclaimid.type
      Control1..?
      Pattern Value{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
          "code" : "uc",
          "display" : "Unique Claim ID"
        }]
      }
      20. ExplanationOfBenefit.type
      BindingThe codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Set
      (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS)
      22. ExplanationOfBenefit.use
      Pattern Valuepredetermination
      24. ExplanationOfBenefit.patient
      TypeReference(HRex Patient Demographics)
      26. ExplanationOfBenefit.created
      ShortThe date and time this estimate was calculated.
      Comments

      The date and time this estimate was calculated based on what was known at that point in time.

      28. ExplanationOfBenefit.insurer
      TypeReference(PCT Organization)
      30. ExplanationOfBenefit.provider
      TypeReference(PCT Practitioner, PCT Organization)
      32. ExplanationOfBenefit.priority
      BindingThe codes SHALL be taken from ProcessPriorityCodes
      (required to http://hl7.org/fhir/ValueSet/process-priority)
      Must Supporttrue
      34. ExplanationOfBenefit.claim
      Control1..?
      36. ExplanationOfBenefit.claim.identifier
      Definition

      Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).

      ShortGFE identifier of the originally submitted claim
      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control1..?
      38. ExplanationOfBenefit.claim.identifier.system
      Must Supporttrue
      40. ExplanationOfBenefit.claim.identifier.value
      Control1..?
      42. ExplanationOfBenefit.insurance
      44. ExplanationOfBenefit.insurance.coverage
      TypeReference(PCT Coverage)
      46. ExplanationOfBenefit.item
      Control1..?
      48. ExplanationOfBenefit.item.extension
      SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 50. ExplanationOfBenefit.item.extension:serviceDescription
        Slice NameserviceDescription
        Control0..1
        This element is affected by the following invariants: pct-aeob-1
        TypeExtension(Service Description) (Extension Type: string)
        Must Supporttrue
        52. ExplanationOfBenefit.item.revenue
        BindingThe codes SHALL be taken from PCT GFE NUBC Revenue Value Set
        (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS)
        54. ExplanationOfBenefit.item.productOrService
        BindingThe codes SHALL be taken from Claim Medical Product or Service Value Set
        (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes)
        56. ExplanationOfBenefit.item.modifier
        Control0..4
        BindingThe codes SHALL be taken from PCT GFE Item CPT - HCPCS Value Set
        (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS)
        Must Supporttrue
        58. ExplanationOfBenefit.item.serviced[x]
        Definition

        This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication

        ShortThis is the planned or estimated date(s)s of service
        Control1..?
        [x] NoteSee Choice of Data Types for further information about how to use [x]
        60. ExplanationOfBenefit.item.quantity
        Must Supporttrue
        62. ExplanationOfBenefit.item.adjudication
        Control1..?
        Must Supporttrue
        SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
        • pattern @ category
        • 64. ExplanationOfBenefit.item.adjudication.category
          BindingUnless not suitable, these codes SHALL be taken from PCT GFE Item Adjudication Value Set
          (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS)
          66. ExplanationOfBenefit.item.adjudication:medicalmanagement
          Slice Namemedicalmanagement
          Control0..*
          Must Supporttrue
          68. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension
          Control1..?
          SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 70. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension:subjectToMedicalMgmt
            Slice NamesubjectToMedicalMgmt
            Control1..1
            TypeExtension(Subject To Medical Management) (Extension Type: CodeableConcept)
            72. ExplanationOfBenefit.item.adjudication:medicalmanagement.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "medicalmanagement"
              }]
            }
            74. ExplanationOfBenefit.item.adjudication:medicalmanagement.amount
            Control0..0
            76. ExplanationOfBenefit.item.adjudication:medicalmanagement.value
            Control0..0
            78. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus
            Slice Namebenefitpaymentstatus
            ShortBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
            Control0..1
            Must Supporttrue
            80. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "benefitpaymentstatus"
              }]
            }
            82. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason
            BindingThe codes SHALL be taken from PCT Payer Benefit Payment Status
            (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
            84. ExplanationOfBenefit.item.adjudication:adjustmentreason
            Slice Nameadjustmentreason
            ShortAdjustment Reason
            Control0..*
            Must Supporttrue
            86. ExplanationOfBenefit.item.adjudication:adjustmentreason.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "adjustmentreason"
              }]
            }
            88. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason
            BindingThe codes SHALL be taken from PCT Adjustment Reason
            (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS)
            90. ExplanationOfBenefit.item.adjudication:submitted
            Slice Namesubmitted
            ShortProvider submitted amount
            Control0..1
            Must Supporttrue
            92. ExplanationOfBenefit.item.adjudication:submitted.category
            Pattern Value{
              "coding" : [{
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "submitted"
              }]
            }
            94. ExplanationOfBenefit.item.adjudication:memberliability
            Slice Namememberliability
            ShortMember liability
            Comments

            $0 is an acceptable value

            Control0..1
            Must Supporttrue
            96. ExplanationOfBenefit.item.adjudication:memberliability.category
            Pattern Value{
              "coding" : [{
                "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                "code" : "memberliability"
              }]
            }
            98. ExplanationOfBenefit.item.adjudication:eligible
            Slice Nameeligible
            ShortEligible amount
            Comments

            Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

            Control0..1
            Must Supporttrue
            100. ExplanationOfBenefit.item.adjudication:eligible.category
            Pattern Value{
              "coding" : [{
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "eligible"
              }]
            }
            102. ExplanationOfBenefit.item.adjudication:benefit
            Slice Namebenefit
            ShortBenefit amount
            Comments

            Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

            Control0..1
            Must Supporttrue
            104. ExplanationOfBenefit.item.adjudication:benefit.category
            Pattern Value{
              "coding" : [{
                "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                "code" : "benefit"
              }]
            }
            106. ExplanationOfBenefit.adjudication
            TypeBackboneElement
            Must Supporttrue
            SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices are unordered and Open, and can be differentiated using the following discriminators:
            • pattern @ category
            • 108. ExplanationOfBenefit.adjudication.category
              BindingUnless not suitable, these codes SHALL be taken from PCT GFE Item Adjudication Value Set
              (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS)
              110. ExplanationOfBenefit.adjudication:medicalmanagement
              Slice Namemedicalmanagement
              Control0..*
              TypeBackboneElement
              Must Supporttrue
              112. ExplanationOfBenefit.adjudication:medicalmanagement.extension
              Control1..?
              SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 114. ExplanationOfBenefit.adjudication:medicalmanagement.extension:subjectToMedicalMgmt
                Slice NamesubjectToMedicalMgmt
                Control1..1
                TypeExtension(Subject To Medical Management) (Extension Type: CodeableConcept)
                116. ExplanationOfBenefit.adjudication:medicalmanagement.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "medicalmanagement"
                  }]
                }
                118. ExplanationOfBenefit.adjudication:medicalmanagement.amount
                Control0..0
                120. ExplanationOfBenefit.adjudication:medicalmanagement.value
                Control0..0
                122. ExplanationOfBenefit.adjudication:billingnetworkstatus
                Slice Namebillingnetworkstatus
                ShortBilling Provider Network Status
                Control0..1
                TypeBackboneElement
                Must Supporttrue
                124. ExplanationOfBenefit.adjudication:billingnetworkstatus.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "billingnetworkstatus"
                  }]
                }
                126. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason
                BindingThe codes SHALL be taken from PCT Payer Benefit Payment Status
                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                128. ExplanationOfBenefit.adjudication:renderingnetworkstatus
                Slice Namerenderingnetworkstatus
                ShortRendering Provider Network Status
                Control0..1
                TypeBackboneElement
                Must Supporttrue
                130. ExplanationOfBenefit.adjudication:renderingnetworkstatus.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "renderingnetworkstatus"
                  }]
                }
                132. ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason
                BindingThe codes SHALL be taken from PCT Payer Benefit Payment Status
                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                134. ExplanationOfBenefit.adjudication:benefitpaymentstatus
                Slice Namebenefitpaymentstatus
                ShortBenefit Payment Status
                Control0..1
                TypeBackboneElement
                Must Supporttrue
                136. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "benefitpaymentstatus"
                  }]
                }
                138. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason
                BindingThe codes SHALL be taken from PCT Payer Benefit Payment Status
                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                140. ExplanationOfBenefit.adjudication:adjustmentreason
                Slice Nameadjustmentreason
                ShortAdjustment Reason
                Control0..*
                TypeBackboneElement
                Must Supporttrue
                142. ExplanationOfBenefit.adjudication:adjustmentreason.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "adjustmentreason"
                  }]
                }
                144. ExplanationOfBenefit.adjudication:adjustmentreason.reason
                BindingThe codes SHALL be taken from PCT Adjustment Reason
                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS)
                146. ExplanationOfBenefit.adjudication:submitted
                Slice Namesubmitted
                ShortProvider submitted amount
                Control0..1
                TypeBackboneElement
                Must Supporttrue
                148. ExplanationOfBenefit.adjudication:submitted.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code" : "submitted"
                  }]
                }
                150. ExplanationOfBenefit.adjudication:memberliability
                Slice Namememberliability
                ShortMember liability
                Comments

                $0 is an acceptable value

                Control0..1
                TypeBackboneElement
                Must Supporttrue
                152. ExplanationOfBenefit.adjudication:memberliability.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                    "code" : "memberliability"
                  }]
                }
                154. ExplanationOfBenefit.adjudication:eligible
                Slice Nameeligible
                ShortEligible amount
                Comments

                Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

                Control0..1
                TypeBackboneElement
                Must Supporttrue
                156. ExplanationOfBenefit.adjudication:eligible.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code" : "eligible"
                  }]
                }
                158. ExplanationOfBenefit.adjudication:benefit
                Slice Namebenefit
                ShortBenefit amount
                Comments

                Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

                Control0..1
                TypeBackboneElement
                Must Supporttrue
                160. ExplanationOfBenefit.adjudication:benefit.category
                Pattern Value{
                  "coding" : [{
                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code" : "benefit"
                  }]
                }
                162. ExplanationOfBenefit.total
                Control1..?
                SlicingThis element introduces a set of slices on ExplanationOfBenefit.total. The slices are unordered and Open, and can be differentiated using the following discriminators:
                • pattern @ category
                • 164. ExplanationOfBenefit.total.category
                  BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                  (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal)
                  Must Supporttrue
                  166. ExplanationOfBenefit.total:submitted
                  Slice Namesubmitted
                  ShortTotal provider submitted amount
                  Control1..1
                  Must Supporttrue
                  168. ExplanationOfBenefit.total:submitted.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code" : "submitted"
                    }]
                  }
                  170. ExplanationOfBenefit.total:memberliability
                  Slice Namememberliability
                  ShortTotal member liability - Must include in non-zero total across all AEoBs
                  Control0..1
                  Must Supporttrue
                  172. ExplanationOfBenefit.total:memberliability.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                      "code" : "memberliability"
                    }]
                  }
                  174. ExplanationOfBenefit.total:innetwork
                  Slice Nameinnetwork
                  ShortTotal in network amount - Must include in non-zero total across all AEoBs
                  Control0..1
                  Must Supporttrue
                  176. ExplanationOfBenefit.total:innetwork.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                      "code" : "innetwork"
                    }]
                  }
                  178. ExplanationOfBenefit.total:outofnetwork
                  Slice Nameoutofnetwork
                  ShortTotal out of network amount - Must include in non-zero total across all AEoBs
                  Control0..1
                  Must Supporttrue
                  180. ExplanationOfBenefit.total:outofnetwork.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                      "code" : "outofnetwork"
                    }]
                  }
                  182. ExplanationOfBenefit.total:noncovered
                  Slice Namenoncovered
                  ShortTotal noncovered amount - Must include in non-zero total across all AEoBs
                  Control0..1
                  Must Supporttrue
                  184. ExplanationOfBenefit.total:noncovered.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
                      "code" : "noncovered"
                    }]
                  }
                  186. ExplanationOfBenefit.total:negotiated
                  Slice Namenegotiated
                  ShortTotal negotiated amount - Must include in non-zero total across all AEoBs
                  Control0..1
                  Must Supporttrue
                  188. ExplanationOfBenefit.total:negotiated.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                      "code" : "negotiated"
                    }]
                  }
                  190. ExplanationOfBenefit.total:eligible
                  Slice Nameeligible
                  ShortTotal eligible amount - Must include in non-zero total across all AEoBs
                  Comments

                  Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

                  Control0..1
                  Must Supporttrue
                  192. ExplanationOfBenefit.total:eligible.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code" : "eligible"
                    }]
                  }
                  194. ExplanationOfBenefit.total:benefit
                  Slice Namebenefit
                  ShortTotal benefit amount - Must include in non-zero total across all AEoBs
                  Comments

                  Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

                  Control0..1
                  Must Supporttrue
                  196. ExplanationOfBenefit.total:benefit.category
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code" : "benefit"
                    }]
                  }
                  198. ExplanationOfBenefit.processNote
                  ShortDisclaimers go here. Notes should be clear and as specific to the situation at hand as possible
                  Control1..?
                  200. ExplanationOfBenefit.processNote.extension
                  SlicingThis element introduces a set of slices on ExplanationOfBenefit.processNote.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                  • value @ url
                  • 202. ExplanationOfBenefit.processNote.extension:processNoteClass
                    Slice NameprocessNoteClass
                    Control0..1
                    TypeExtension(ProcessNote Class) (Extension Type: CodeableConcept)
                    204. ExplanationOfBenefit.benefitPeriod
                    Control1..?
                    206. ExplanationOfBenefit.benefitBalance
                    Control1..?
                    208. ExplanationOfBenefit.benefitBalance.category
                    BindingThe codes SHALL be taken from PCT benefitBalance.category codes
                    (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS)
                    210. ExplanationOfBenefit.benefitBalance.unit
                    Control1..?
                    BindingThe codes SHALL be taken from UnitTypeCodes
                    (required to http://hl7.org/fhir/ValueSet/benefit-unit)
                    212. ExplanationOfBenefit.benefitBalance.term
                    Control1..?
                    BindingThe codes SHALL be taken from BenefitTermCodes
                    (required to http://hl7.org/fhir/ValueSet/benefit-term)
                    214. ExplanationOfBenefit.benefitBalance.financial
                    Control1..?
                    216. ExplanationOfBenefit.benefitBalance.financial.extension
                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.benefitBalance.financial.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                    • value @ url
                    • 218. ExplanationOfBenefit.benefitBalance.financial.extension:remaining
                      Slice Nameremaining
                      Control0..1
                      TypeExtension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money)
                      Must Supporttrue
                      220. ExplanationOfBenefit.benefitBalance.financial.type
                      BindingThe codes SHALL be taken from PCT Financial Type Value Set
                      (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS)
                      222. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
                      Control1..?
                      TypeChoice of: unsignedInt, Money, string
                      [x] NoteSee Choice of Data Types for further information about how to use [x]
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Must Support TypesChoice of: unsignedInt, Money, string
                      224. ExplanationOfBenefit.benefitBalance.financial.used[x]
                      Control1..?
                      TypeChoice of: unsignedInt, Money
                      [x] NoteSee Choice of Data Types for further information about how to use [x]
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Must Support TypesChoice of: unsignedInt, Money

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

                      0. ExplanationOfBenefit
                      Definition

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

                      ShortExplanation of Benefit resource
                      Control0..*
                      Is Modifierfalse
                      Summaryfalse
                      Alternate NamesEOB
                      Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
                      dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
                      dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
                      dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
                      dom-6: A resource should have narrative for robust management (text.`div`.exists())
                      pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists())
                      pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists())
                      pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists())
                      2. ExplanationOfBenefit.implicitRules
                      Definition

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

                      ShortA set of rules under which this content was created
                      Comments

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

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

                      An Extension


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

                      ShortExtensionAdditional content defined by implementations
                      Comments

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

                      Control10..*
                      TypeExtension
                      Is Modifierfalse
                      Summaryfalse
                      Alternate Namesextensions, user content
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                      • value @ url
                      • 6. ExplanationOfBenefit.extension:gfeReference
                        Slice NamegfeReference
                        Definition

                        This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.

                        ShortThe GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
                        Control1..*
                        This element is affected by the following invariants: ele-1
                        TypeExtension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle))
                        Is Modifierfalse
                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        8. ExplanationOfBenefit.extension:serviceDescription
                        Slice NameserviceDescription
                        Definition

                        This extension is used to communicate a plain language description of the procedure, product, or service.

                        ShortService Description
                        Control0..1
                        This element is affected by the following invariants: ele-1, pct-aeob-1
                        TypeExtension(Service Description) (Extension Type: string)
                        Is Modifierfalse
                        Must Supporttrue
                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        10. ExplanationOfBenefit.extension:outOfNetworkProviderInfo
                        Slice NameoutOfNetworkProviderInfo
                        Definition

                        This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.

                        ShortIn Network Provider Options Link
                        Control0..1
                        This element is affected by the following invariants: ele-1
                        TypeExtension(In Network Provider Options Link) (Extension Type: url)
                        Is Modifierfalse
                        Must Supporttrue
                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        12. ExplanationOfBenefit.modifierExtension
                        Definition

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

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

                        ShortExtensions that cannot be ignored
                        Comments

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

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

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

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

                        A unique identifier assigned to this explanation of benefit.

                        ShortBusiness Identifier for the resource
                        NoteThis is a business identifier, not a resource identifier (see discussion)
                        Control10..*
                        TypeIdentifier
                        Is Modifierfalse
                        Summaryfalse
                        Requirements

                        Allows EOBs to be distinguished and referenced.

                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
                        • pattern @ type
                        • 16. ExplanationOfBenefit.identifier:INTER
                          Slice NameINTER
                          Definition

                          A unique identifier assigned to this explanation of benefit.

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

                          Allows EOBs to be distinguished and referenced.

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

                          The purpose of this identifier.

                          Shortusual | official | temp | secondary | old (If known)
                          Comments

                          Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                          Control0..1
                          BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
                          (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                          Identifies the purpose for this identifier, if known .

                          Typecode
                          Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Requirements

                          Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                          A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

                          ShortDescription of identifier
                          Comments

                          This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

                          Control10..1
                          BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type
                          (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

                          A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summarytrue
                          Requirements

                          Allows users to make use of identifiers when the identifier system is not known.

                          Pattern Value{
                            "coding" : [{
                              "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
                              "code" : "INTER",
                              "display" : "Intermediary System Identifier"
                            }]
                          }
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          22. ExplanationOfBenefit.identifier:uniqueclaimid
                          Slice Nameuniqueclaimid
                          Definition

                          A unique identifier assigned to this explanation of benefit.

                          ShortUnique Claim IDBusiness Identifier for the resource
                          NoteThis is a business identifier, not a resource identifier (see discussion)
                          Control10..1*
                          TypeIdentifier
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Allows EOBs to be distinguished and referenced.

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

                          The purpose of this identifier.

                          Shortusual | official | temp | secondary | old (If known)
                          Comments

                          Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                          Control0..1
                          BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
                          (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                          Identifies the purpose for this identifier, if known .

                          Typecode
                          Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Requirements

                          Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                          A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

                          ShortDescription of identifier
                          Comments

                          This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

                          Control10..1
                          BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type
                          (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

                          A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summarytrue
                          Requirements

                          Allows users to make use of identifiers when the identifier system is not known.

                          Pattern Value{
                            "coding" : [{
                              "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
                              "code" : "uc",
                              "display" : "Unique Claim ID"
                            }]
                          }
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          28. ExplanationOfBenefit.status
                          Definition

                          The status of the resource instance.

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

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

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

                          A code specifying the state of the resource instance.

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

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

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

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

                          ShortCategory or discipline
                          Comments

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

                          Control1..1
                          BindingThe codes SHALL be taken from Unless not suitable, these codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Sethttp://hl7.org/fhir/ValueSet/claim-type
                          (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS)
                          TypeCodeableConcept
                          Is Modifierfalse
                          Summarytrue
                          Requirements

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

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

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

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

                          Complete, proposed, exploratory, other.

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

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

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

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

                          ShortThe recipient of the products and services
                          Control1..1
                          TypeReference(HRex Patient Demographics, Patient)
                          Is Modifierfalse
                          Summarytrue
                          Requirements

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

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

                          The date this resource was created.

                          ShortThe date and time this estimate was calculated.Response creation date
                          Comments

                          The date and time this estimate was calculated based on what was known at that point in time.


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

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

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

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

                          The party responsible for authorization, adjudication and reimbursement.

                          ShortParty responsible for reimbursement
                          Control1..1
                          TypeReference(PCT Organization, Organization)
                          Is Modifierfalse
                          Summarytrue
                          Requirements

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

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

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

                          ShortParty responsible for the claim
                          Comments

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

                          Control1..1
                          TypeReference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization)
                          Is Modifierfalse
                          Summarytrue
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          42. ExplanationOfBenefit.priority
                          Definition

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

                          ShortDesired processing urgency
                          Comments

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

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

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

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

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

                          ShortClaim reference
                          Control10..1
                          TypeReference(Claim)
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          To provide a link to the original adjudication request.

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

                          Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).


                          An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

                          ShortGFE identifier of the originally submitted claimLogical reference, when literal reference is not known
                          Comments

                          When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                          When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                          Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                          Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                          NoteThis is a business identifier, not a resource identifier (see discussion)
                          Control10..1
                          TypeIdentifier
                          Is Modifierfalse
                          Summarytrue
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          48. ExplanationOfBenefit.claim.identifier.use
                          Definition

                          The purpose of this identifier.

                          Shortusual | official | temp | secondary | old (If known)
                          Comments

                          Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                          Control0..1
                          BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
                          (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                          Identifies the purpose for this identifier, if known .

                          Typecode
                          Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Requirements

                          Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                          Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

                          ShortThe namespace for the identifier value
                          Comments

                          Identifier.system is always case sensitive.

                          Control0..1
                          Typeuri
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Must Supporttrue
                          Summarytrue
                          Requirements

                          There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

                          Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          52. ExplanationOfBenefit.claim.identifier.value
                          Definition

                          The portion of the identifier typically relevant to the user and which is unique within the context of the system.

                          ShortThe value that is unique
                          Comments

                          If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

                          Control10..1
                          Typestring
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Example<br/><b>General</b>:123456
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          54. ExplanationOfBenefit.outcome
                          Definition

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

                          Shortqueued | complete | error | partial
                          Comments

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

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

                          The result of the claim processing.

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

                          To advise the requestor of an overall processing outcome.

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

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

                          ShortPatient insurance information
                          Comments

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

                          Control1..*
                          TypeBackboneElement
                          Is Modifierfalse
                          Summarytrue
                          Requirements

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

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

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

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

                          ShortExtensions that cannot be ignored even if unrecognized
                          Comments

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

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

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

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

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

                          ShortCoverage to be used for adjudication
                          Comments

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

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

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

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

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

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

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

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

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

                          ShortProduct or service provided
                          Control10..*
                          TypeBackboneElement
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          The items to be processed for adjudication.

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

                          An Extension


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

                          ShortExtensionAdditional content defined by implementations
                          Comments

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

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

                            This extension is used to communicate a plain language description of the procedure, product, or service.

                            ShortService Description
                            Control0..1
                            This element is affected by the following invariants: ele-1, pct-aeob-1
                            TypeExtension(Service Description) (Extension Type: string)
                            Is Modifierfalse
                            Must Supporttrue
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            70. ExplanationOfBenefit.item.modifierExtension
                            Definition

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

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

                            ShortExtensions that cannot be ignored even if unrecognized
                            Comments

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

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

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

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

                            A number to uniquely identify item entries.

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

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

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

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

                            ShortRevenue or cost center code
                            Control0..1
                            BindingThe codes SHALL be taken from For example codes, see PCT GFE NUBC Revenue Value Sethttp://hl7.org/fhir/ValueSet/ex-revenue-center
                            (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS)
                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Needed in the processing of institutional claims.

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

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

                            ShortBilling, service, product, or drug code
                            Comments

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

                            Control1..1
                            BindingThe codes SHALL be taken from For example codes, see Claim Medical Product or Service Value Sethttp://hl7.org/fhir/ValueSet/service-uscls
                            (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes)
                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Necessary to state what was provided or done.

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

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

                            ShortProduct or service billing modifiers
                            Comments

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

                            Control0..4*
                            BindingThe codes SHALL be taken from For example codes, see PCT GFE Item CPT - HCPCS Value Sethttp://hl7.org/fhir/ValueSet/claim-modifiers
                            (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS)
                            TypeCodeableConcept
                            Is Modifierfalse
                            Must Supporttrue
                            Summaryfalse
                            Requirements

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

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

                            This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication


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

                            ShortThis is the planned or estimated date(s)s of serviceDate or dates of service or product delivery
                            Control10..1
                            TypeChoice of: date, Period
                            [x] NoteSee Choice of Data Types for further information about how to use [x]
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

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

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

                            The number of repetitions of a service or product.

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

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

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

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

                            ShortAdjudication details
                            Control10..*
                            TypeBackboneElement
                            Is Modifierfalse
                            Must Supporttrue
                            Summaryfalse
                            Requirements

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

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

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

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

                              ShortExtensions that cannot be ignored even if unrecognized
                              Comments

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

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

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

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

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

                              ShortType of adjudication information
                              Comments

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

                              Control1..1
                              BindingUnless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Sethttp://hl7.org/fhir/ValueSet/adjudication
                              (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS)
                              TypeCodeableConcept
                              Is Modifierfalse
                              Summaryfalse
                              Requirements

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

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

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

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

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

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

                              An Extension


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

                              ShortExtensionAdditional content defined by implementations
                              Comments

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

                              Control10..*
                              TypeExtension
                              Is Modifierfalse
                              Summaryfalse
                              Alternate Namesextensions, user content
                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                              SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                              • value @ url
                              • 94. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension:subjectToMedicalMgmt
                                Slice NamesubjectToMedicalMgmt
                                Definition

                                This extension is used to provide a reason to explain how the estimate may change subject to medical management.

                                ShortSubject To Medical Management
                                Control1..1
                                This element is affected by the following invariants: ele-1
                                TypeExtension(Subject To Medical Management) (Extension Type: CodeableConcept)
                                Is Modifierfalse
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                96. ExplanationOfBenefit.item.adjudication:medicalmanagement.modifierExtension
                                Definition

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

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

                                Monetary amount associated with the category.

                                ShortMonetary amount
                                Comments

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

                                Control0..01
                                TypeMoney
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

                                Most adjuciation categories convey a monetary amount.

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

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

                                ShortNon-monitary value
                                Comments

                                For example: eligible percentage or co-payment percentage.

                                Control0..01
                                Typedecimal
                                Is Modifierfalse
                                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                Summaryfalse
                                Requirements

                                Some adjudication categories convey a percentage or a fixed value.

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

                                ShortBenefit Payment Status: Line level benefit payment status associated with professional claim estimates only.Adjudication details
                                Control0..1*
                                TypeBackboneElement
                                Is Modifierfalse
                                Must Supporttrue
                                Summaryfalse
                                Requirements

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

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

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

                                ShortExplanation of adjudication outcome
                                Comments

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

                                Control0..1
                                BindingThe codes SHALL be taken from For example codes, see PCT Payer Benefit Payment Statushttp://hl7.org/fhir/ValueSet/adjudication-reason
                                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

                                To support understanding of variance from adjudication expectations.

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

                                ShortAdjustment ReasonAdjudication details
                                Control0..*
                                TypeBackboneElement
                                Is Modifierfalse
                                Must Supporttrue
                                Summaryfalse
                                Requirements

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

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

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

                                ShortExplanation of adjudication outcome
                                Comments

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

                                Control0..1
                                BindingThe codes SHALL be taken from For example codes, see PCT Adjustment Reasonhttp://hl7.org/fhir/ValueSet/adjudication-reason
                                (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS)
                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

                                To support understanding of variance from adjudication expectations.

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

                                ShortProvider submitted amountAdjudication details
                                Control0..1*
                                TypeBackboneElement
                                Is Modifierfalse
                                Must Supporttrue
                                Summaryfalse
                                Requirements

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

                                Pattern Value{
                                  "coding" : [{
                                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                    "code" : "submitted"
                                  }]
                                }
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                126. ExplanationOfBenefit.item.adjudication:memberliability
                                Slice Namememberliability
                                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.

                                ShortMember liabilityAdjudication details
                                Comments

                                $0 is an acceptable value

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

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

                                Pattern Value{
                                  "coding" : [{
                                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                                    "code" : "memberliability"
                                  }]
                                }
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                132. ExplanationOfBenefit.item.adjudication:eligible
                                Slice Nameeligible
                                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.

                                ShortEligible amountAdjudication details
                                Comments

                                Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

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

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

                                Pattern Value{
                                  "coding" : [{
                                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                    "code" : "eligible"
                                  }]
                                }
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                138. ExplanationOfBenefit.item.adjudication:benefit
                                Slice Namebenefit
                                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.

                                ShortBenefit amountAdjudication details
                                Comments

                                Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

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

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

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

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

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

                                ShortExtensions that cannot be ignored even if unrecognized
                                Comments

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

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

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

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

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

                                ShortType of adjudication information
                                Comments

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

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

                                The adjudication codes.

                                TypeCodeableConcept
                                Is Modifierfalse
                                Summaryfalse
                                Requirements

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

                                Pattern Value{
                                  "coding" : [{
                                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                    "code" : "benefit"
                                  }]
                                }
                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                144. ExplanationOfBenefit.adjudication
                                Definition

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

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

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

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

                                  ShortExtensions that cannot be ignored even if unrecognized
                                  Comments

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

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

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

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

                                  ShortType of adjudication information
                                  Comments

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

                                  Control1..1
                                  BindingUnless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Sethttp://hl7.org/fhir/ValueSet/adjudication
                                  (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjudicationCategoryVS)
                                  TypeCodeableConcept
                                  Is Modifierfalse
                                  Summaryfalse
                                  Requirements

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

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

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

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

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

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

                                  An Extension


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

                                  ShortExtensionAdditional content defined by implementations
                                  Comments

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

                                  Control10..*
                                  TypeExtension
                                  Is Modifierfalse
                                  Summaryfalse
                                  Alternate Namesextensions, user content
                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                  SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                                  • value @ url
                                  • 154. ExplanationOfBenefit.adjudication:medicalmanagement.extension:subjectToMedicalMgmt
                                    Slice NamesubjectToMedicalMgmt
                                    Definition

                                    This extension is used to provide a reason to explain how the estimate may change subject to medical management.

                                    ShortSubject To Medical Management
                                    Control1..1
                                    This element is affected by the following invariants: ele-1
                                    TypeExtension(Subject To Medical Management) (Extension Type: CodeableConcept)
                                    Is Modifierfalse
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                    156. ExplanationOfBenefit.adjudication:medicalmanagement.modifierExtension
                                    Definition

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

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

                                    Monetary amount associated with the category.

                                    ShortMonetary amount
                                    Comments

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

                                    Control0..01
                                    TypeMoney
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

                                    Most adjuciation categories convey a monetary amount.

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

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

                                    ShortNon-monitary value
                                    Comments

                                    For example: eligible percentage or co-payment percentage.

                                    Control0..01
                                    Typedecimal
                                    Is Modifierfalse
                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                    Summaryfalse
                                    Requirements

                                    Some adjudication categories convey a percentage or a fixed value.

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

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

                                    ShortBilling Provider Network StatusHeader-level adjudication
                                    Control0..1*
                                    TypeBackboneElement
                                    Is Modifierfalse
                                    Must Supporttrue
                                    Summaryfalse
                                    Requirements

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

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

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

                                    ShortExplanation of adjudication outcome
                                    Comments

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

                                    Control0..1
                                    BindingThe codes SHALL be taken from For example codes, see PCT Payer Benefit Payment Statushttp://hl7.org/fhir/ValueSet/adjudication-reason
                                    (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

                                    To support understanding of variance from adjudication expectations.

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

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

                                    ShortRendering Provider Network StatusHeader-level adjudication
                                    Control0..1*
                                    TypeBackboneElement
                                    Is Modifierfalse
                                    Must Supporttrue
                                    Summaryfalse
                                    Requirements

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

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

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

                                    ShortExplanation of adjudication outcome
                                    Comments

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

                                    Control0..1
                                    BindingThe codes SHALL be taken from For example codes, see PCT Payer Benefit Payment Statushttp://hl7.org/fhir/ValueSet/adjudication-reason
                                    (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

                                    To support understanding of variance from adjudication expectations.

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

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

                                    ShortBenefit Payment StatusHeader-level adjudication
                                    Control0..1*
                                    TypeBackboneElement
                                    Is Modifierfalse
                                    Must Supporttrue
                                    Summaryfalse
                                    Requirements

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

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

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

                                    ShortExplanation of adjudication outcome
                                    Comments

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

                                    Control0..1
                                    BindingThe codes SHALL be taken from For example codes, see PCT Payer Benefit Payment Statushttp://hl7.org/fhir/ValueSet/adjudication-reason
                                    (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTPayerBenefitPaymentStatusVS)
                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

                                    To support understanding of variance from adjudication expectations.

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

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

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

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

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

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

                                    ShortExplanation of adjudication outcome
                                    Comments

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

                                    Control0..1
                                    BindingThe codes SHALL be taken from For example codes, see PCT Adjustment Reasonhttp://hl7.org/fhir/ValueSet/adjudication-reason
                                    (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS)
                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

                                    To support understanding of variance from adjudication expectations.

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

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

                                    ShortProvider submitted amountHeader-level adjudication
                                    Control0..1*
                                    TypeBackboneElement
                                    Is Modifierfalse
                                    Must Supporttrue
                                    Summaryfalse
                                    Requirements

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

                                    Pattern Value{
                                      "coding" : [{
                                        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                        "code" : "submitted"
                                      }]
                                    }
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    202. ExplanationOfBenefit.adjudication:memberliability
                                    Slice Namememberliability
                                    Definition

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

                                    ShortMember liabilityHeader-level adjudication
                                    Comments

                                    $0 is an acceptable value

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

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

                                    Pattern Value{
                                      "coding" : [{
                                        "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                                        "code" : "memberliability"
                                      }]
                                    }
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    208. ExplanationOfBenefit.adjudication:eligible
                                    Slice Nameeligible
                                    Definition

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

                                    ShortEligible amountHeader-level adjudication
                                    Comments

                                    Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

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

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

                                    Pattern Value{
                                      "coding" : [{
                                        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                        "code" : "eligible"
                                      }]
                                    }
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    214. ExplanationOfBenefit.adjudication:benefit
                                    Slice Namebenefit
                                    Definition

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

                                    ShortBenefit amountHeader-level adjudication
                                    Comments

                                    Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.

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

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

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

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

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

                                    ShortExtensions that cannot be ignored even if unrecognized
                                    Comments

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

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

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

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

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

                                    ShortType of adjudication information
                                    Comments

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

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

                                    The adjudication codes.

                                    TypeCodeableConcept
                                    Is Modifierfalse
                                    Summaryfalse
                                    Requirements

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

                                    Pattern Value{
                                      "coding" : [{
                                        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                        "code" : "benefit"
                                      }]
                                    }
                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    220. ExplanationOfBenefit.total
                                    Definition

                                    Categorized monetary totals for the adjudication.

                                    ShortAdjudication totals
                                    Comments

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

                                    Control10..*
                                    TypeBackboneElement
                                    Is Modifierfalse
                                    Summarytrue
                                    Requirements

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

                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.total. The slices are unordered and Open, and can be differentiated using the following discriminators:
                                    • pattern @ category
                                    • 222. ExplanationOfBenefit.total.modifierExtension
                                      Definition

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

                                      Alternate Namesextensions, user content, modifiers
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                      224. 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.

                                      ShortType of adjudication information
                                      Comments

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

                                      Control1..1
                                      BindingUnless not suitable, these codes SHALL be taken from For example codes, see PCT Total Value Sethttp://hl7.org/fhir/ValueSet/adjudication
                                      (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal)
                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

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

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal provider submitted amountAdjudication totals
                                      Comments

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

                                      Control10..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                          "code" : "submitted"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      234. ExplanationOfBenefit.total:submitted.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal member liability - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS",
                                          "code" : "memberliability"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      242. ExplanationOfBenefit.total:memberliability.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal in network amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "innetwork"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      250. ExplanationOfBenefit.total:innetwork.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal out of network amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "outofnetwork"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      258. ExplanationOfBenefit.total:outofnetwork.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal noncovered amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
                                          "code" : "noncovered"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      266. ExplanationOfBenefit.total:noncovered.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal negotiated amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "negotiated"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      274. ExplanationOfBenefit.total:negotiated.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal eligible amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

                                      Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.


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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                          "code" : "eligible"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      282. ExplanationOfBenefit.total:eligible.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      Categorized monetary totals for the adjudication.

                                      ShortTotal benefit amount - Must include in non-zero total across all AEoBsAdjudication totals
                                      Comments

                                      Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.


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

                                      Control0..1*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Must Supporttrue
                                      Summarytrue
                                      Requirements

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

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

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

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

                                      ShortExtensions that cannot be ignored even if unrecognized
                                      Comments

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

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

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

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

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

                                      ShortType of adjudication information
                                      Comments

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

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

                                      The adjudication codes.

                                      TypeCodeableConcept
                                      Is Modifierfalse
                                      Summarytrue
                                      Requirements

                                      Needed to convey the type of total provided.

                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                          "code" : "benefit"
                                        }]
                                      }
                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                      290. ExplanationOfBenefit.total:benefit.amount
                                      Definition

                                      Monetary total amount associated with the category.

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

                                      Needed to convey the total monetary amount.

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

                                      A note that describes or explains adjudication results in a human readable form.

                                      ShortDisclaimers go here. Notes should be clear and as specific to the situation at hand as possibleNote concerning adjudication
                                      Control10..*
                                      TypeBackboneElement
                                      Is Modifierfalse
                                      Summaryfalse
                                      Requirements

                                      Provides the insurer specific textual explanations associated with the processing.

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

                                      An Extension


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

                                      ShortExtensionAdditional content defined by implementations
                                      Comments

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

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

                                        This extension is used to indicate a the class of AEOB Claim process notes

                                        ShortProcessNote Class
                                        Control0..1
                                        This element is affected by the following invariants: ele-1
                                        TypeExtension(ProcessNote Class) (Extension Type: CodeableConcept)
                                        Is Modifierfalse
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                        298. 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).

                                        ShortExtensions that cannot be ignored even if unrecognized
                                        Comments

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

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

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

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

                                        The term of the benefits documented in this response.

                                        ShortWhen the benefits are applicable
                                        Comments

                                        Not applicable when use=claim.

                                        Control10..1
                                        TypePeriod
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

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

                                        Balance by Benefit Category.

                                        ShortBalance by Benefit Category
                                        Control10..*
                                        TypeBackboneElement
                                        Is Modifierfalse
                                        Summaryfalse
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        304. 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).

                                        ShortExtensions that cannot be ignored even if unrecognized
                                        Comments

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

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

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

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

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

                                        ShortBenefit classification
                                        Comments

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

                                        Control1..1
                                        BindingThe codes SHALL be taken from For example codes, see PCT benefitBalance.category codeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory
                                        (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS)
                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Needed to convey the category of service or product for which eligibility is sought.

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

                                        Indicates if the benefits apply to an individual or to the family.

                                        ShortIndividual or family
                                        Control10..1
                                        BindingThe codes SHALL be taken from For example codes, see UnitTypeCodeshttp://hl7.org/fhir/ValueSet/benefit-unit
                                        (required to http://hl7.org/fhir/ValueSet/benefit-unit)
                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Needed for the understanding of the benefits.

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

                                        The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.

                                        ShortAnnual or lifetime
                                        Control10..1
                                        BindingThe codes SHALL be taken from For example codes, see BenefitTermCodeshttp://hl7.org/fhir/ValueSet/benefit-term
                                        (required to http://hl7.org/fhir/ValueSet/benefit-term)
                                        TypeCodeableConcept
                                        Is Modifierfalse
                                        Summaryfalse
                                        Requirements

                                        Needed for the understanding of the benefits.

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

                                        Benefits Used to date.

                                        ShortBenefit Summary
                                        Control10..*
                                        TypeBackboneElement
                                        Is Modifierfalse
                                        Summaryfalse
                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                        314. ExplanationOfBenefit.benefitBalance.financial.extension
                                        Definition

                                        An Extension


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

                                        ShortExtensionAdditional content defined by implementations
                                        Comments

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

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

                                          The quantity of the benefit remaining to date.

                                          ShortBenefit Remaining
                                          Control0..1
                                          This element is affected by the following invariants: ele-1
                                          TypeExtension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money)
                                          Is Modifierfalse
                                          Must Supporttrue
                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                          318. 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).

                                          ShortExtensions that cannot be ignored even if unrecognized
                                          Comments

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

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

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

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

                                          Classification of benefit being provided.

                                          ShortBenefit classification
                                          Comments

                                          For example: deductible, visits, benefit amount.

                                          Control1..1
                                          BindingThe codes SHALL be taken from For example codes, see PCT Financial Type Value Sethttp://hl7.org/fhir/ValueSet/benefit-type
                                          (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS)
                                          TypeCodeableConcept
                                          Is Modifierfalse
                                          Summaryfalse
                                          Requirements

                                          Needed to convey the nature of the benefit.

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

                                          The quantity of the benefit which is permitted under the coverage.

                                          ShortBenefits allowed
                                          Control10..1
                                          TypeChoice of: unsignedInt, Money, string
                                          [x] NoteSee Choice of Data Types for further information about how to use [x]
                                          Is Modifierfalse
                                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                          Must Supporttrue
                                          Must Support TypesChoice of: unsignedInt, Money, string
                                          Summaryfalse
                                          Requirements

                                          Needed to convey the benefits offered under the coverage.

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

                                          The quantity of the benefit which have been consumed to date.

                                          ShortBenefits used
                                          Control10..1
                                          TypeChoice of: unsignedInt, Money
                                          [x] NoteSee Choice of Data Types for further information about how to use [x]
                                          Is Modifierfalse
                                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                          Must Supporttrue
                                          Must Support TypesChoice of: unsignedInt, Money
                                          Summaryfalse
                                          Requirements

                                          Needed to convey the benefits consumed to date.

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

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

                                          0. ExplanationOfBenefit
                                          Definition

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

                                          ShortExplanation of Benefit resource
                                          Control0..*
                                          Is Modifierfalse
                                          Summaryfalse
                                          Alternate NamesEOB
                                          Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
                                          dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
                                          dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
                                          dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
                                          dom-6: A resource should have narrative for robust management (text.`div`.exists())
                                          pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists())
                                          pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists())
                                          pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists())
                                          2. ExplanationOfBenefit.id
                                          Definition

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

                                          ShortLogical id of this artifact
                                          Comments

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

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

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

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

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

                                          ShortA set of rules under which this content was created
                                          Comments

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

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

                                          The base language in which the resource is written.

                                          ShortLanguage of the resource content
                                          Comments

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

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

                                          A human language.

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

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

                                          ShortText summary of the resource, for human interpretation
                                          Comments

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

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

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

                                          ShortContained, inline Resources
                                          Comments

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

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

                                          An Extension

                                          ShortExtension
                                          Control1..*
                                          TypeExtension
                                          Is Modifierfalse
                                          Summaryfalse
                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                          SlicingThis element introduces a set of slices on ExplanationOfBenefit.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
                                          • value @ url
                                          • 16. ExplanationOfBenefit.extension:gfeReference
                                            Slice NamegfeReference
                                            Definition

                                            This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.

                                            ShortThe GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
                                            Control1..*
                                            This element is affected by the following invariants: ele-1
                                            TypeExtension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle))
                                            Is Modifierfalse
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            18. ExplanationOfBenefit.extension:serviceDescription
                                            Slice NameserviceDescription
                                            Definition

                                            This extension is used to communicate a plain language description of the procedure, product, or service.

                                            ShortService Description
                                            Control0..1
                                            This element is affected by the following invariants: ele-1, pct-aeob-1
                                            TypeExtension(Service Description) (Extension Type: string)
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            20. ExplanationOfBenefit.extension:outOfNetworkProviderInfo
                                            Slice NameoutOfNetworkProviderInfo
                                            Definition

                                            This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.

                                            ShortIn Network Provider Options Link
                                            Control0..1
                                            This element is affected by the following invariants: ele-1
                                            TypeExtension(In Network Provider Options Link) (Extension Type: url)
                                            Is Modifierfalse
                                            Must Supporttrue
                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                            22. ExplanationOfBenefit.modifierExtension
                                            Definition

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

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

                                            ShortExtensions that cannot be ignored
                                            Comments

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

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

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

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

                                            A unique identifier assigned to this explanation of benefit.

                                            ShortBusiness Identifier for the resource
                                            NoteThis is a business identifier, not a resource identifier (see discussion)
                                            Control1..*
                                            TypeIdentifier
                                            Is Modifierfalse
                                            Summaryfalse
                                            Requirements

                                            Allows EOBs to be distinguished and referenced.

                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                            SlicingThis element introduces a set of slices on ExplanationOfBenefit.identifier. The slices are unordered and Open, and can be differentiated using the following discriminators:
                                            • pattern @ type
                                            • 26. ExplanationOfBenefit.identifier:INTER
                                              Slice NameINTER
                                              Definition

                                              A unique identifier assigned to this explanation of benefit.

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

                                              Allows EOBs to be distinguished and referenced.

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

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

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

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

                                              ShortAdditional content defined by implementations
                                              Comments

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

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

                                                The purpose of this identifier.

                                                Shortusual | official | temp | secondary | old (If known)
                                                Comments

                                                Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                                                Control0..1
                                                BindingThe codes SHALL be taken from IdentifierUse
                                                (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                                                Identifies the purpose for this identifier, if known .

                                                Typecode
                                                Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                                                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                Summarytrue
                                                Requirements

                                                Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                                                A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

                                                ShortDescription of identifier
                                                Comments

                                                This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

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

                                                A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

                                                TypeCodeableConcept
                                                Is Modifierfalse
                                                Summarytrue
                                                Requirements

                                                Allows users to make use of identifiers when the identifier system is not known.

                                                Pattern Value{
                                                  "coding" : [{
                                                    "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
                                                    "code" : "INTER",
                                                    "display" : "Intermediary System Identifier"
                                                  }]
                                                }
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                36. ExplanationOfBenefit.identifier:INTER.system
                                                Definition

                                                Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

                                                ShortThe namespace for the identifier value
                                                Comments

                                                Identifier.system is always case sensitive.

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

                                                There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

                                                Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                38. ExplanationOfBenefit.identifier:INTER.value
                                                Definition

                                                The portion of the identifier typically relevant to the user and which is unique within the context of the system.

                                                ShortThe value that is unique
                                                Comments

                                                If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

                                                Control0..1
                                                Typestring
                                                Is Modifierfalse
                                                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                Summarytrue
                                                Example<br/><b>General</b>:123456
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                40. ExplanationOfBenefit.identifier:INTER.period
                                                Definition

                                                Time period during which identifier is/was valid for use.

                                                ShortTime period when id is/was valid for use
                                                Control0..1
                                                TypePeriod
                                                Is Modifierfalse
                                                Summarytrue
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                42. ExplanationOfBenefit.identifier:INTER.assigner
                                                Definition

                                                Organization that issued/manages the identifier.

                                                ShortOrganization that issued id (may be just text)
                                                Comments

                                                The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

                                                Control0..1
                                                TypeReference(Organization)
                                                Is Modifierfalse
                                                Summarytrue
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                44. ExplanationOfBenefit.identifier:uniqueclaimid
                                                Slice Nameuniqueclaimid
                                                Definition

                                                A unique identifier assigned to this explanation of benefit.

                                                ShortUnique Claim ID
                                                NoteThis is a business identifier, not a resource identifier (see discussion)
                                                Control1..1
                                                TypeIdentifier
                                                Is Modifierfalse
                                                Summaryfalse
                                                Requirements

                                                Allows EOBs to be distinguished and referenced.

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

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

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

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

                                                ShortAdditional content defined by implementations
                                                Comments

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

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

                                                  The purpose of this identifier.

                                                  Shortusual | official | temp | secondary | old (If known)
                                                  Comments

                                                  Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                                                  Control0..1
                                                  BindingThe codes SHALL be taken from IdentifierUse
                                                  (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                                                  Identifies the purpose for this identifier, if known .

                                                  Typecode
                                                  Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                  Summarytrue
                                                  Requirements

                                                  Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                                                  A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

                                                  ShortDescription of identifier
                                                  Comments

                                                  This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

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

                                                  A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Requirements

                                                  Allows users to make use of identifiers when the identifier system is not known.

                                                  Pattern Value{
                                                    "coding" : [{
                                                      "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTIdentifierType",
                                                      "code" : "uc",
                                                      "display" : "Unique Claim ID"
                                                    }]
                                                  }
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  54. ExplanationOfBenefit.identifier:uniqueclaimid.system
                                                  Definition

                                                  Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

                                                  ShortThe namespace for the identifier value
                                                  Comments

                                                  Identifier.system is always case sensitive.

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

                                                  There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

                                                  Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  56. ExplanationOfBenefit.identifier:uniqueclaimid.value
                                                  Definition

                                                  The portion of the identifier typically relevant to the user and which is unique within the context of the system.

                                                  ShortThe value that is unique
                                                  Comments

                                                  If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

                                                  Control0..1
                                                  Typestring
                                                  Is Modifierfalse
                                                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                  Summarytrue
                                                  Example<br/><b>General</b>:123456
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  58. ExplanationOfBenefit.identifier:uniqueclaimid.period
                                                  Definition

                                                  Time period during which identifier is/was valid for use.

                                                  ShortTime period when id is/was valid for use
                                                  Control0..1
                                                  TypePeriod
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  60. ExplanationOfBenefit.identifier:uniqueclaimid.assigner
                                                  Definition

                                                  Organization that issued/manages the identifier.

                                                  ShortOrganization that issued id (may be just text)
                                                  Comments

                                                  The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

                                                  Control0..1
                                                  TypeReference(Organization)
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  62. ExplanationOfBenefit.status
                                                  Definition

                                                  The status of the resource instance.

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

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

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

                                                  A code specifying the state of the resource instance.

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

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

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

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

                                                  ShortCategory or discipline
                                                  Comments

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

                                                  Control1..1
                                                  BindingThe codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Set
                                                  (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS)
                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Requirements

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

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

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

                                                  ShortMore granular claim type
                                                  Comments

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

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

                                                  A more granular claim typecode.

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

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

                                                  Complete, proposed, exploratory, other.

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

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

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

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

                                                  ShortThe recipient of the products and services
                                                  Control1..1
                                                  TypeReference(HRex Patient Demographics)
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Requirements

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

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

                                                  The period for which charges are being submitted.

                                                  ShortRelevant time frame for the claim
                                                  Comments

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

                                                  Control0..1
                                                  TypePeriod
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Requirements

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

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

                                                  The date this resource was created.

                                                  ShortThe date and time this estimate was calculated.
                                                  Comments

                                                  The date and time this estimate was calculated based on what was known at that point in time.

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

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

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

                                                  Individual who created the claim, predetermination or preauthorization.

                                                  ShortAuthor of the claim
                                                  Control0..1
                                                  TypeReference(Practitioner, PractitionerRole)
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

                                                  Some jurisdictions require the contact information for personnel completing claims.

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

                                                  The party responsible for authorization, adjudication and reimbursement.

                                                  ShortParty responsible for reimbursement
                                                  Control1..1
                                                  TypeReference(PCT Organization)
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Requirements

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

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

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

                                                  ShortParty responsible for the claim
                                                  Comments

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

                                                  Control1..1
                                                  TypeReference(PCT Practitioner, PCT Organization)
                                                  Is Modifierfalse
                                                  Summarytrue
                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                  82. ExplanationOfBenefit.priority
                                                  Definition

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

                                                  ShortDesired processing urgency
                                                  Comments

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

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

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

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

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

                                                  ShortFor whom to reserve funds
                                                  Comments

                                                  This field is only used for preauthorizations.

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

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

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

                                                  ShortFunds reserved status
                                                  Comments

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

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

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

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

                                                  ShortPrior or corollary claims
                                                  Comments

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

                                                  Control0..*
                                                  TypeBackboneElement
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

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

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

                                                  ShortAdditional content defined by implementations
                                                  Comments

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

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

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

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

                                                  ShortExtensions that cannot be ignored even if unrecognized
                                                  Comments

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

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

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

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

                                                  Reference to a related claim.

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

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

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

                                                  A code to convey how the claims are related.

                                                  ShortHow the reference claim is related
                                                  Comments

                                                  For example, prior claim or umbrella.

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

                                                  Relationship of this claim to a related Claim.

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

                                                  Some insurers need a declaration of the type of relationship.

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

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

                                                  ShortFile or case reference
                                                  Comments

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

                                                  Control0..1
                                                  TypeIdentifier
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

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

                                                  Required to authorize the dispensing of controlled substances and devices.

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

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

                                                  ShortOriginal prescription if superceded by fulfiller
                                                  Comments

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

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

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

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

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

                                                  ShortRecipient of benefits payable
                                                  Comments

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

                                                  Control0..1
                                                  TypeBackboneElement
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

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

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

                                                  ShortAdditional content defined by implementations
                                                  Comments

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

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

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

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

                                                  ShortExtensions that cannot be ignored even if unrecognized
                                                  Comments

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

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

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

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

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

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

                                                  A code for the party to be reimbursed.

                                                  TypeCodeableConcept
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

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

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

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

                                                  ShortRecipient reference
                                                  Comments

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

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

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

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

                                                  A reference to a referral resource.

                                                  ShortTreatment Referral
                                                  Comments

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

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

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

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

                                                  Facility where the services were provided.

                                                  ShortServicing Facility
                                                  Control0..1
                                                  TypeReference(Location)
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

                                                  Insurance adjudication can be dependant on where services were delivered.

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

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

                                                  ShortClaim reference
                                                  Control1..1
                                                  TypeReference(Claim)
                                                  Is Modifierfalse
                                                  Summaryfalse
                                                  Requirements

                                                  To provide a link to the original adjudication request.

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

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

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

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

                                                  ShortAdditional content defined by implementations
                                                  Comments

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

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

                                                    A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

                                                    ShortLiteral reference, Relative, internal or absolute URL
                                                    Comments

                                                    Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

                                                    Control0..1
                                                    This element is affected by the following invariants: ref-1
                                                    Typestring
                                                    Is Modifierfalse
                                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                    Summarytrue
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    130. ExplanationOfBenefit.claim.type
                                                    Definition

                                                    The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

                                                    The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

                                                    ShortType the reference refers to (e.g. "Patient")
                                                    Comments

                                                    This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

                                                    Control0..1
                                                    BindingUnless not suitable, these codes SHALL be taken from ResourceType
                                                    (extensible to http://hl7.org/fhir/ValueSet/resource-types)

                                                    Aa resource (or, for logical models, the URI of the logical model).

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

                                                    Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).

                                                    ShortGFE identifier of the originally submitted claim
                                                    Comments

                                                    When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                                                    When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                                                    Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                                                    Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                                                    NoteThis is a business identifier, not a resource identifier (see discussion)
                                                    Control1..1
                                                    TypeIdentifier
                                                    Is Modifierfalse
                                                    Summarytrue
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    134. ExplanationOfBenefit.claim.identifier.id
                                                    Definition

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

                                                      The purpose of this identifier.

                                                      Shortusual | official | temp | secondary | old (If known)
                                                      Comments

                                                      Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

                                                      Control0..1
                                                      BindingThe codes SHALL be taken from IdentifierUse
                                                      (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

                                                      Identifies the purpose for this identifier, if known .

                                                      Typecode
                                                      Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
                                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                      Summarytrue
                                                      Requirements

                                                      Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

                                                      A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

                                                      ShortDescription of identifier
                                                      Comments

                                                      This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

                                                      Control0..1
                                                      BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
                                                      (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

                                                      A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

                                                      TypeCodeableConcept
                                                      Is Modifierfalse
                                                      Summarytrue
                                                      Requirements

                                                      Allows users to make use of identifiers when the identifier system is not known.

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

                                                      Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

                                                      ShortThe namespace for the identifier value
                                                      Comments

                                                      Identifier.system is always case sensitive.

                                                      Control0..1
                                                      Typeuri
                                                      Is Modifierfalse
                                                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                      Must Supporttrue
                                                      Summarytrue
                                                      Requirements

                                                      There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

                                                      Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
                                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                      144. ExplanationOfBenefit.claim.identifier.value