Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 - Draft 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 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 foundhere

0. ExplanationOfBenefit
Definition

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

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: Advanced 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: Advanced 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: Advanced 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 areUnordered 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
    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())
    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
    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())
    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
    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())
    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 areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ type
    • 16. 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()))
      18. 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()))
      20. 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://terminology.hl7.org/CodeSystem/v2-0203",
          "code" : "UCID"
        }]
      }
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. 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()))
      24. 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 ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
      (required to http://hl7.org/fhir/ValueSet/claim-type)
      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()))
      26. 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()))
      28. ExplanationOfBenefit.patient
      Definition

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

      ShortThe recipient of the products and services
      Control1..1
      TypeReference(US Core Patient Profile, Patient)
      Is Modifierfalse
      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()))
      30. 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()))
      32. 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()))
      34. 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()))
      36. 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://hl7.org/fhir/ValueSet/process-priority
      (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()))
      38. 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()))
      40. 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()))
      42. 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()))
      44. 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.

      ExampleGeneral: http://www.acme.com/identifiers/patient
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      46. 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
      ExampleGeneral: 123456
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      48. 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()))
      50. 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()))
      52. 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())
      54. 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()))
      56. 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()))
      58. 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()))
      60. ExplanationOfBenefit.item.extension
      Definition

      An Extension


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

      ShortExtensionAdditional content defined by implementations
      Comments

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

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 62. 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
        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())
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        64. 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())
        66. 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()))
        68. 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()))
        70. 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()))
        72. ExplanationOfBenefit.item.productOrService.coding
        Definition

        A reference to a code defined by a terminology system.

        ShortCode defined by a terminology system
        Comments

        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

        Control0..*
        TypeCoding
        Is Modifierfalse
        Summarytrue
        Requirements

        Allows for alternative encodings within a code system, and translations to other code systems.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
        74. 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()))
        76. ExplanationOfBenefit.item.modifier.coding
        Definition

        A reference to a code defined by a terminology system.

        ShortCode defined by a terminology system
        Comments

        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

        Control0..*
        TypeCoding
        Is Modifierfalse
        Summarytrue
        Requirements

        Allows for alternative encodings within a code system, and translations to other code systems.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
        78. 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] NoteSeeChoice of Data Typesfor further information about how to use [x]
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

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

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        80. 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()))
        82. 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 areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ category
        • 84. 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())
          86. 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()))
          88. 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()))
          90. 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 areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 92. 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: Choice of: string, CodeableConcept)
            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())
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            94. 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())
            96. 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
            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.

            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()))
            98. 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()))
            100. 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()))
            102. 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()))
            104. 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())
            106. 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
            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.

            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()))
            108. 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()))
            110. 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()))
            112. 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())
            114. 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
            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.

            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()))
            116. 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()))
            118. 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()))
            120. 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())
            122. 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
            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.

            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()))
            124. 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()))
            126. 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())
            128. 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
            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.

            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()))
            130. 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()))
            132. 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())
            134. 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
            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.

            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()))
            136. 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()))
            138. 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())
            140. 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
            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.

            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()))
            142. ExplanationOfBenefit.adjudication
            Definition

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

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

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

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            SlicingThis element introduces a set of slices on ExplanationOfBenefit.adjudication. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ category
            • 144. 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())
              146. 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()))
              148. 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()))
              150. 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 areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 152. 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: Choice of: string, CodeableConcept)
                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())
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                154. 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())
                156. 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
                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.

                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()))
                158. 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()))
                160. 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()))
                162. 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()))
                164. 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())
                166. 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
                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.

                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()))
                168. 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()))
                170. 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()))
                172. 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())
                174. 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
                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.

                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()))
                176. 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()))
                178. 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()))
                180. 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())
                182. 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
                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.

                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()))
                184. 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()))
                186. 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()))
                188. 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())
                190. 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
                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.

                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()))
                192. 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()))
                194. 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()))
                196. 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())
                198. 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
                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.

                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()))
                200. 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()))
                202. 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())
                204. 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
                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.

                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()))
                206. 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()))
                208. 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())
                210. 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
                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.

                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()))
                212. 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()))
                214. 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())
                216. 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
                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.

                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()))
                218. ExplanationOfBenefit.total
                Definition

                Categorized monetary totals for the adjudication.

                ShortAdjudication totals
                Comments

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

                Control30..*
                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 areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ category
                • 220. 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())
                  222. 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()))
                  224. 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()))
                  226. 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()))
                  228. 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())
                  230. 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
                  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.

                  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()))
                  232. 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()))
                  234. 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.

                  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()))
                  236. 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())
                  238. 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
                  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.

                  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()))
                  240. 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()))
                  242. 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.

                  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()))
                  244. 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())
                  246. 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
                  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.

                  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()))
                  248. 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()))
                  250. 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()))
                  252. 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())
                  254. 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
                  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.

                  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()))
                  256. 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()))
                  258. 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()))
                  260. 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())
                  262. 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
                  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.

                  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()))
                  264. 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()))
                  266. 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()))
                  268. 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())
                  270. 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
                  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.

                  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()))
                  272. 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()))
                  274. ExplanationOfBenefit.total:negotiated
                  Slice Namenegotiated
                  Definition

                  Categorized monetary totals for the adjudication.

                  ShortTotal negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contractAdjudication 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()))
                  276. 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())
                  278. 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
                  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.

                  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()))
                  280. 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()))
                  282. 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()))
                  284. 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())
                  286. 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
                  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.

                  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()))
                  288. 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()))
                  290. 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 possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.Note concerning adjudication
                  Comments

                  These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.

                  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()))
                  292. 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 areUnordered and Open, and can be differentiated using the following discriminators:
                  • value @ url
                  • 294. 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
                    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())
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    296. 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())
                    298. 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()))
                    300. ExplanationOfBenefit.benefitBalance
                    Definition

                    Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.


                    Balance by Benefit Category.

                    ShortEstimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.Balance 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()))
                    302. 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())
                    304. 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()))
                    306. ExplanationOfBenefit.benefitBalance.category.text
                    Definition

                    A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                    ShortPlain text representation of the concept
                    Comments

                    Very often the text is the same as a displayName of one of the codings.

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

                    The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

                    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 areUnordered 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
                      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())
                      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] NoteSeeChoice of Data Typesfor further information about how to use [x]
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      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] NoteSeeChoice of Data Typesfor further information about how to use [x]
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      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 foundhere

                      0. ExplanationOfBenefit
                      Invariantspct-aeob-1: Advanced 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: Advanced 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: Advanced 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 areUnordered 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 areUnordered and Open, and can be differentiated using the following discriminators:
                        • value @ type
                        • 12. ExplanationOfBenefit.identifier:uniqueclaimid
                          Slice Nameuniqueclaimid
                          ShortUnique Claim ID
                          NoteThis is a business identifier, not a resource identifier (see discussion)
                          Control1..1
                          14. ExplanationOfBenefit.identifier:uniqueclaimid.type
                          Control1..?
                          Pattern Value{
                            "coding" : [{
                              "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                              "code" : "UCID"
                            }]
                          }
                          16. ExplanationOfBenefit.type
                          BindingThe codes SHALL be taken from ClaimTypeCodes
                          (required to http://hl7.org/fhir/ValueSet/claim-type)
                          18. ExplanationOfBenefit.use
                          Pattern Valuepredetermination
                          20. ExplanationOfBenefit.patient
                          TypeReference(US Core Patient Profile)
                          22. 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.

                          24. ExplanationOfBenefit.insurer
                          TypeReference(PCT Organization)
                          26. ExplanationOfBenefit.provider
                          TypeReference(PCT Practitioner, PCT Organization)
                          28. ExplanationOfBenefit.priority
                          BindingThe codes SHALL be taken from ProcessPriorityCodes
                          (required to http://hl7.org/fhir/ValueSet/process-priority)
                          Must Supporttrue
                          30. ExplanationOfBenefit.claim
                          Control1..?
                          32. 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..?
                          34. ExplanationOfBenefit.claim.identifier.system
                          Must Supporttrue
                          36. ExplanationOfBenefit.claim.identifier.value
                          Control1..?
                          38. ExplanationOfBenefit.insurance
                          40. ExplanationOfBenefit.insurance.coverage
                          TypeReference(PCT Coverage)
                          42. ExplanationOfBenefit.item
                          Control1..?
                          44. ExplanationOfBenefit.item.extension
                          SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                          • value @ url
                          • 46. 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
                            48. 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)
                            50. 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)
                            52. ExplanationOfBenefit.item.productOrService.coding
                            Invariantspct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
                            54. 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
                            56. ExplanationOfBenefit.item.modifier.coding
                            Invariantspct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
                            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] NoteSeeChoice of Data Typesfor 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 areUnordered and Open, and can be differentiated using the following discriminators:
                            • value @ 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 areUnordered 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: Choice of: string, 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 areUnordered and Open, and can be differentiated using the following discriminators:
                                • value @ 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 areUnordered 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: Choice of: string, 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
                                    Control3..?
                                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.total. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                    • value @ 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
                                      Control1..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: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.

                                      Control1..1
                                      Must Supporttrue
                                      176. ExplanationOfBenefit.total:eligible.category
                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                                          "code" : "eligible"
                                        }]
                                      }
                                      178. ExplanationOfBenefit.total:innetwork
                                      Slice Nameinnetwork
                                      ShortTotal in network amount - Must include in non-zero total across all AEoBs
                                      Control0..1
                                      Must Supporttrue
                                      180. ExplanationOfBenefit.total:innetwork.category
                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "innetwork"
                                        }]
                                      }
                                      182. ExplanationOfBenefit.total:outofnetwork
                                      Slice Nameoutofnetwork
                                      ShortTotal out of network amount - Must include in non-zero total across all AEoBs
                                      Control0..1
                                      Must Supporttrue
                                      184. ExplanationOfBenefit.total:outofnetwork.category
                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "outofnetwork"
                                        }]
                                      }
                                      186. ExplanationOfBenefit.total:noncovered
                                      Slice Namenoncovered
                                      ShortTotal noncovered amount - Must include in non-zero total across all AEoBs
                                      Control0..1
                                      Must Supporttrue
                                      188. ExplanationOfBenefit.total:noncovered.category
                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication",
                                          "code" : "noncovered"
                                        }]
                                      }
                                      190. ExplanationOfBenefit.total:negotiated
                                      Slice Namenegotiated
                                      ShortTotal negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
                                      Control0..1
                                      Must Supporttrue
                                      192. ExplanationOfBenefit.total:negotiated.category
                                      Pattern Value{
                                        "coding" : [{
                                          "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS",
                                          "code" : "negotiated"
                                        }]
                                      }
                                      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 including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
                                      Comments

                                      These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.

                                      Control1..?
                                      200. ExplanationOfBenefit.processNote.extension
                                      SlicingThis element introduces a set of slices on ExplanationOfBenefit.processNote.extension. The slices areUnordered 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
                                        Definition

                                        Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.

                                        ShortEstimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
                                        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.category.text
                                        Control1..?
                                        Must Supporttrue
                                        212. ExplanationOfBenefit.benefitBalance.unit
                                        Control1..?
                                        BindingThe codes SHALL be taken from UnitTypeCodes
                                        (required to http://hl7.org/fhir/ValueSet/benefit-unit)
                                        214. ExplanationOfBenefit.benefitBalance.term
                                        Control1..?
                                        BindingThe codes SHALL be taken from BenefitTermCodes
                                        (required to http://hl7.org/fhir/ValueSet/benefit-term)
                                        216. ExplanationOfBenefit.benefitBalance.financial
                                        Control1..?
                                        218. ExplanationOfBenefit.benefitBalance.financial.extension
                                        SlicingThis element introduces a set of slices on ExplanationOfBenefit.benefitBalance.financial.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                        • value @ url
                                        • 220. ExplanationOfBenefit.benefitBalance.financial.extension:remaining
                                          Slice Nameremaining
                                          Control0..1
                                          TypeExtension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money)
                                          Must Supporttrue
                                          222. 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)
                                          224. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
                                          Control1..?
                                          TypeChoice of: unsignedInt, Money, string
                                          [x] NoteSeeChoice of Data Typesfor 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
                                          226. ExplanationOfBenefit.benefitBalance.financial.used[x]
                                          Control1..?
                                          TypeChoice of: unsignedInt, Money
                                          [x] NoteSeeChoice of Data Typesfor 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 foundhere

                                          0. ExplanationOfBenefit
                                          Definition

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

                                          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: Advanced 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: Advanced 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: Advanced 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 areUnordered 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
                                            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())
                                            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
                                            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())
                                            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
                                            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())
                                            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 areUnordered and Open, and can be differentiated using the following discriminators:
                                            • value @ type
                                            • 26. 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()))
                                              28. 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
                                              30. 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 areUnordered and Open, and can be differentiated using the following discriminators:
                                              • value @ url
                                              • 32. 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()))
                                                34. 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://terminology.hl7.org/CodeSystem/v2-0203",
                                                    "code" : "UCID"
                                                  }]
                                                }
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                36. 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.

                                                ExampleGeneral: 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: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
                                                ExampleGeneral: 123456
                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                40. 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()))
                                                42. 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()))
                                                44. 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()))
                                                46. 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 ClaimTypeCodes
                                                (required to http://hl7.org/fhir/ValueSet/claim-type)
                                                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()))
                                                48. 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()))
                                                50. 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()))
                                                52. ExplanationOfBenefit.patient
                                                Definition

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

                                                ShortThe recipient of the products and services
                                                Control1..1
                                                TypeReference(US Core Patient Profile)
                                                Is Modifierfalse
                                                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()))
                                                54. 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()))
                                                56. 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()))
                                                58. 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()))
                                                60. 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()))
                                                62. 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()))
                                                64. 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()))
                                                66. 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()))
                                                68. 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()))
                                                70. 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()))
                                                72. 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
                                                74. 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())
                                                76. 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())
                                                78. 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()))
                                                80. 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()))
                                                82. 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()))
                                                84. 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()))
                                                86. 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()))
                                                88. 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()))
                                                90. 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
                                                92. 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())
                                                94. 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())
                                                96. 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()))
                                                98. 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()))
                                                100. 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()))
                                                102. 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()))
                                                104. 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()))
                                                106. 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
                                                108. 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 areUnordered and Open, and can be differentiated using the following discriminators:
                                                • value @ url
                                                • 110. 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()))
                                                  112. 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()))
                                                  114. 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()))
                                                  116. 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
                                                  118. 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 areUnordered and Open, and can be differentiated using the following discriminators:
                                                  • value @ url
                                                  • 120. 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()))
                                                    122. 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()))
                                                    124. 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.

                                                    ExampleGeneral: http://www.acme.com/identifiers/patient
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    126. 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.

                                                    Control1..1
                                                    Typestring
                                                    Is Modifierfalse
                                                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                    Summarytrue
                                                    ExampleGeneral: 123456
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    128. ExplanationOfBenefit.claim.identifier.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()))
                                                    130. ExplanationOfBenefit.claim.identifier.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()))
                                                    132. ExplanationOfBenefit.claim.display
                                                    Definition

                                                    Plain text narrative that identifies the resource in addition to the resource reference.

                                                    ShortText alternative for the resource
                                                    Comments

                                                    This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

                                                    Control0..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()))
                                                    134. ExplanationOfBenefit.claimResponse
                                                    Definition

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

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

                                                    To provide a link to the original adjudication response.

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

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

                                                    Shortqueued | complete | error | partial
                                                    Comments

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

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

                                                    The result of the claim processing.

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

                                                    To advise the requestor of an overall processing outcome.

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

                                                    A human readable description of the status of the adjudication.

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

                                                    Provided for user display.

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

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

                                                    ShortPreauthorization reference
                                                    Comments

                                                    This value is only present on preauthorization adjudications.

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

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

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

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

                                                    ShortPreauthorization in-effect period
                                                    Comments

                                                    This value is only present on preauthorization adjudications.

                                                    Control0..*
                                                    TypePeriod
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

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

                                                    Common to identify the responsible and supporting practitioners.

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

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

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

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

                                                    ShortExtensions that cannot be ignored even if unrecognized
                                                    Comments

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

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

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

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

                                                    A number to uniquely identify care team entries.

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

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

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

                                                    Member of the team who provided the product or service.

                                                    ShortPractitioner or organization
                                                    Control1..1
                                                    TypeReference(Practitioner, PractitionerRole, Organization)
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

                                                    Often a regulatory requirement to specify the responsible provider.

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

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

                                                    ShortIndicator of the lead practitioner
                                                    Comments

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

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

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

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

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

                                                    ShortFunction within the team
                                                    Comments

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

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

                                                    The role codes for the care team members.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

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

                                                    Provider professional qualifications.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

                                                    ShortSupporting information
                                                    Comments

                                                    Often there are multiple jurisdiction specific valuesets which are required.

                                                    Control0..*
                                                    TypeBackboneElement
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

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

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

                                                    ShortExtensions that cannot be ignored even if unrecognized
                                                    Comments

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

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

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

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

                                                    A number to uniquely identify supporting information entries.

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

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

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

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

                                                    ShortClassification of the supplied information
                                                    Comments

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

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

                                                    The valuset used for additional information category codes.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

                                                    ShortType of information
                                                    Comments

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

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

                                                    The valuset used for additional information codes.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

                                                    Required to identify the kind of additional information.

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

                                                    The date when or period to which this information refers.

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

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

                                                    ShortData to be provided
                                                    Comments

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

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

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

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

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

                                                    ShortExplanation for the information
                                                    Comments

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

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

                                                    Reason codes for the missing teeth.

                                                    TypeCoding
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

                                                    Information about diagnoses relevant to the claim items.

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

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

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

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

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

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

                                                    ShortExtensions that cannot be ignored even if unrecognized
                                                    Comments

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

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

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

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

                                                    A number to uniquely identify diagnosis entries.

                                                    ShortDiagnosis instance identifier
                                                    Comments

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

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

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

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

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

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

                                                    ICD10 Diagnostic codes.

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

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

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

                                                    When the condition was observed or the relative ranking.

                                                    ShortTiming or nature of the diagnosis
                                                    Comments

                                                    For example: admitting, primary, secondary, discharge.

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

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

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

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

                                                    Present on admission.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

                                                    ShortPackage billing code
                                                    Comments

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

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

                                                    The DRG codes associated with the diagnosis.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

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

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

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

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

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

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

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

                                                    ShortExtensions that cannot be ignored even if unrecognized
                                                    Comments

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

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

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

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

                                                    A number to uniquely identify procedure entries.

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

                                                    Necessary to provide a mechanism to link to claim details.

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

                                                    When the condition was observed or the relative ranking.

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

                                                    Example procedure type codes.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

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

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

                                                    Date and optionally time the procedure was performed.

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

                                                    Required for auditing purposes.

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

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

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

                                                    ICD10 Procedure codes.

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

                                                    This identifies the actual clinical procedure.

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

                                                    Unique Device Identifiers associated with this line item.

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

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

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

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

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

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

                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    220. 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()))
                                                    222. ExplanationOfBenefit.insurance.id
                                                    Definition

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

                                                    Control0..*
                                                    TypeExtension
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Alternate Namesextensions, user content
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                                    226. 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())
                                                    228. 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()))
                                                    230. 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)
                                                    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()))
                                                    232. ExplanationOfBenefit.insurance.preAuthRef
                                                    Definition

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

                                                    ShortPrior authorization reference number
                                                    Comments

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

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

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

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

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

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

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

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

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

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

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

                                                    ShortAdditional content defined by implementations
                                                    Comments

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

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

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

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

                                                    ShortExtensions that cannot be ignored even if unrecognized
                                                    Comments

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

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

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

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

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

                                                    ShortWhen the incident occurred
                                                    Comments

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

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

                                                    Required for audit purposes and adjudication.

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

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

                                                    ShortThe nature of the accident
                                                    Control0..1
                                                    BindingUnless not suitable, these codes SHALL be taken from ActIncidentCode (3.0.0)
                                                    (extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0)

                                                    Type of accident: work place, auto, etc.

                                                    TypeCodeableConcept
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Requirements

                                                    Coverage may be dependant on the type of accident.

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

                                                    The physical location of the accident event.

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

                                                    Required for audit purposes and determination of applicable insurance liability.

                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    248. 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
                                                    Control1..*
                                                    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()))
                                                    250. ExplanationOfBenefit.item.id
                                                    Definition

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

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

                                                    An Extension

                                                    ShortExtension
                                                    Control0..*
                                                    TypeExtension
                                                    Is Modifierfalse
                                                    Summaryfalse
                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                    • value @ url
                                                    • 254. 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
                                                      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())
                                                      256. 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())
                                                      258. 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()))
                                                      260. ExplanationOfBenefit.item.careTeamSequence
                                                      Definition

                                                      Care team members related to this service or product.

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

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

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

                                                      Diagnoses applicable for this service or product.

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

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

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

                                                      Procedures applicable for this service or product.

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

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

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

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

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

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

                                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                      268. 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 PCT GFE NUBC Revenue Value Set
                                                      (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()))
                                                      270. ExplanationOfBenefit.item.category
                                                      Definition

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

                                                      ShortBenefit classification
                                                      Comments

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

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

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

                                                      TypeCodeableConcept
                                                      Is Modifierfalse
                                                      Summaryfalse
                                                      Requirements

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

                                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                      272. 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 Claim Medical Product or Service Value Set
                                                      (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()))
                                                      274. ExplanationOfBenefit.item.productOrService.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
                                                      276. ExplanationOfBenefit.item.productOrService.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.item.productOrService.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                      • value @ url
                                                      • 278. ExplanationOfBenefit.item.productOrService.coding
                                                        Definition

                                                        A reference to a code defined by a terminology system.

                                                        ShortCode defined by a terminology system
                                                        Comments

                                                        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

                                                        Control0..*
                                                        TypeCoding
                                                        Is Modifierfalse
                                                        Summarytrue
                                                        Requirements

                                                        Allows for alternative encodings within a code system, and translations to other code systems.

                                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                        pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
                                                        280. ExplanationOfBenefit.item.productOrService.text
                                                        Definition

                                                        A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                                                        ShortPlain text representation of the concept
                                                        Comments

                                                        Very often the text is the same as a displayName of one of the codings.

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

                                                        The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

                                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                        282. 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 PCT GFE Item CPT - HCPCS Value Set
                                                        (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()))
                                                        284. ExplanationOfBenefit.item.modifier.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
                                                        286. ExplanationOfBenefit.item.modifier.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.item.modifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                        • value @ url
                                                        • 288. ExplanationOfBenefit.item.modifier.coding
                                                          Definition

                                                          A reference to a code defined by a terminology system.

                                                          ShortCode defined by a terminology system
                                                          Comments

                                                          Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

                                                          Control0..*
                                                          TypeCoding
                                                          Is Modifierfalse
                                                          Summarytrue
                                                          Requirements

                                                          Allows for alternative encodings within a code system, and translations to other code systems.

                                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                          pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (system = 'http://www.ama-assn.org/go/cpt' implies display.exists())
                                                          290. ExplanationOfBenefit.item.modifier.text
                                                          Definition

                                                          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                                                          ShortPlain text representation of the concept
                                                          Comments

                                                          Very often the text is the same as a displayName of one of the codings.

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

                                                          The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

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

                                                          Identifies the program under which this may be recovered.

                                                          ShortProgram the product or service is provided under
                                                          Comments

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

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

                                                          Program specific reason codes.

                                                          TypeCodeableConcept
                                                          Is Modifierfalse
                                                          Summaryfalse
                                                          Requirements

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

                                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                          294. 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..1
                                                          TypeChoice of: date, Period
                                                          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                                          Is Modifierfalse
                                                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                          Summaryfalse
                                                          Requirements

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

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

                                                          Where the product or service was provided.

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

                                                          Place where the service is rendered.

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

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

                                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                          298. 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()))
                                                          300. ExplanationOfBenefit.item.unitPrice
                                                          Definition

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

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

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

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

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

                                                          ShortPrice scaling factor
                                                          Comments

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

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

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

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

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

                                                          ShortTotal item cost
                                                          Comments

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

                                                          Control0..1
                                                          TypeMoney
                                                          Is Modifierfalse
                                                          Summaryfalse
                                                          Requirements

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

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

                                                          Unique Device Identifiers associated with this line item.

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

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

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

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

                                                          ShortAnatomical location
                                                          Comments

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

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

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

                                                          TypeCodeableConcept
                                                          Is Modifierfalse
                                                          Summaryfalse
                                                          Requirements

                                                          Allows insurer to validate specific procedures.

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

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

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

                                                          The code for the tooth surface and surface combinations.

                                                          TypeCodeableConcept
                                                          Is Modifierfalse
                                                          Summaryfalse
                                                          Requirements

                                                          Allows insurer to validate specific procedures.

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

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

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

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

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

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

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

                                                          Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

                                                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                          316. 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
                                                          Control1..*
                                                          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 areUnordered and Open, and can be differentiated using the following discriminators:
                                                          • value @ category
                                                          • 318. ExplanationOfBenefit.item.adjudication.id
                                                            Definition

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

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

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

                                                            ShortAdditional content defined by implementations
                                                            Comments

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

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

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

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

                                                            ShortExtensions that cannot be ignored even if unrecognized
                                                            Comments

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

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

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

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

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

                                                            ShortExplanation of adjudication outcome
                                                            Comments

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

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

                                                            Adjudication reason codes.

                                                            TypeCodeableConcept
                                                            Is Modifierfalse
                                                            Summaryfalse
                                                            Requirements

                                                            To support understanding of variance from adjudication expectations.

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

                                                            Monetary amount associated with the category.

                                                            ShortMonetary amount
                                                            Comments

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

                                                            Control0..1
                                                            TypeMoney
                                                            Is Modifierfalse
                                                            Summaryfalse
                                                            Requirements

                                                            Most adjuciation categories convey a monetary amount.

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

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

                                                            ShortNon-monitary value
                                                            Comments

                                                            For example: eligible percentage or co-payment percentage.

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

                                                            Some adjudication categories convey a percentage or a fixed value.

                                                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                            332. 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()))
                                                            334. ExplanationOfBenefit.item.adjudication:medicalmanagement.id
                                                            Definition

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

                                                            ShortUnique id for inter-element referencing
                                                            Control0..1
                                                            Typestring
                                                            Is Modifierfalse
                                                            XML FormatIn the XML format, this property is represented as an attribute.
                                                            Summaryfalse
                                                            336. ExplanationOfBenefit.item.adjudication:medicalmanagement.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.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                            • value @ url
                                                            • 338. 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: Choice of: string, CodeableConcept)
                                                              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())
                                                              340. 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())
                                                              342. 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
                                                              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)
                                                              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()))
                                                              344. ExplanationOfBenefit.item.adjudication:medicalmanagement.reason
                                                              Definition

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

                                                              ShortExplanation of adjudication outcome
                                                              Comments

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

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

                                                              Adjudication reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              To support understanding of variance from adjudication expectations.

                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              346. 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..0
                                                              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()))
                                                              348. 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..0
                                                              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()))
                                                              350. 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.
                                                              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()))
                                                              352. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.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
                                                              354. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.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())
                                                              356. 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())
                                                              358. 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
                                                              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)
                                                              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()))
                                                              360. 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 PCT Payer Benefit Payment Status
                                                              (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()))
                                                              362. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.amount
                                                              Definition

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              366. 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 Reason
                                                              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()))
                                                              368. ExplanationOfBenefit.item.adjudication:adjustmentreason.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
                                                              370. ExplanationOfBenefit.item.adjudication:adjustmentreason.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())
                                                              372. 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())
                                                              374. 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
                                                              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)
                                                              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()))
                                                              376. 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 PCT Adjustment 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()))
                                                              378. ExplanationOfBenefit.item.adjudication:adjustmentreason.amount
                                                              Definition

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              382. 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 amount
                                                              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()))
                                                              384. ExplanationOfBenefit.item.adjudication:submitted.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
                                                              386. ExplanationOfBenefit.item.adjudication:submitted.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())
                                                              388. 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())
                                                              390. 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
                                                              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)
                                                              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()))
                                                              392. ExplanationOfBenefit.item.adjudication:submitted.reason
                                                              Definition

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

                                                              ShortExplanation of adjudication outcome
                                                              Comments

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

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

                                                              Adjudication reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              To support understanding of variance from adjudication expectations.

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

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

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

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

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

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

                                                              ShortAdditional content defined by implementations
                                                              Comments

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

                                                              Control0..*
                                                              TypeExtension
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Alternate Namesextensions, user content
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                                              404. ExplanationOfBenefit.item.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())
                                                              406. 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
                                                              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)
                                                              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()))
                                                              408. ExplanationOfBenefit.item.adjudication:memberliability.reason
                                                              Definition

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

                                                              ShortExplanation of adjudication outcome
                                                              Comments

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

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

                                                              Adjudication reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              To support understanding of variance from adjudication expectations.

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

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              414. 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 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
                                                              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()))
                                                              416. ExplanationOfBenefit.item.adjudication:eligible.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
                                                              418. ExplanationOfBenefit.item.adjudication:eligible.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())
                                                              420. 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())
                                                              422. 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
                                                              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)
                                                              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()))
                                                              424. ExplanationOfBenefit.item.adjudication:eligible.reason
                                                              Definition

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

                                                              ShortExplanation of adjudication outcome
                                                              Comments

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

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

                                                              Adjudication reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              To support understanding of variance from adjudication expectations.

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

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              430. 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 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
                                                              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()))
                                                              432. ExplanationOfBenefit.item.adjudication:benefit.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
                                                              434. ExplanationOfBenefit.item.adjudication:benefit.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())
                                                              436. 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())
                                                              438. 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
                                                              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)
                                                              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()))
                                                              440. ExplanationOfBenefit.item.adjudication:benefit.reason
                                                              Definition

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

                                                              ShortExplanation of adjudication outcome
                                                              Comments

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

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

                                                              Adjudication reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              To support understanding of variance from adjudication expectations.

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

                                                              Monetary amount associated with the category.

                                                              ShortMonetary amount
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Most adjuciation categories convey a monetary amount.

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

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

                                                              ShortNon-monitary value
                                                              Comments

                                                              For example: eligible percentage or co-payment percentage.

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

                                                              Some adjudication categories convey a percentage or a fixed value.

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

                                                              Second-tier of goods and services.

                                                              ShortAdditional items
                                                              Control0..*
                                                              TypeBackboneElement
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              448. ExplanationOfBenefit.item.detail.id
                                                              Definition

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

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

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

                                                              ShortAdditional content defined by implementations
                                                              Comments

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

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

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

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

                                                              ShortExtensions that cannot be ignored even if unrecognized
                                                              Comments

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

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

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

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

                                                              A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

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

                                                              The items to be processed for adjudication.

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

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Needed in the processing of institutional claims.

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

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

                                                              ShortBenefit classification
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

                                                              ShortBilling, service, product, or drug code
                                                              Comments

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

                                                              Control1..1
                                                              BindingFor example codes, see USCLSCodes
                                                              (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                                              Allowable service and product codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Necessary to state what was provided or done.

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

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

                                                              ShortService/Product billing modifiers
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              Identifies the program under which this may be recovered.

                                                              ShortProgram the product or service is provided under
                                                              Comments

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

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

                                                              Program specific reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              The number of repetitions of a service or product.

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

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

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

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

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

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

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

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

                                                              ShortPrice scaling factor
                                                              Comments

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

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

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

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

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

                                                              ShortTotal item cost
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              Unique Device Identifiers associated with this line item.

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

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

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

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

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

                                                              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

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

                                                              The adjudication results.

                                                              ShortDetail level adjudication details
                                                              Control0..*
                                                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              480. ExplanationOfBenefit.item.detail.subDetail
                                                              Definition

                                                              Third-tier of goods and services.

                                                              ShortAdditional items
                                                              Control0..*
                                                              TypeBackboneElement
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              482. ExplanationOfBenefit.item.detail.subDetail.id
                                                              Definition

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

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

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

                                                              ShortAdditional content defined by implementations
                                                              Comments

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

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

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

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

                                                              ShortExtensions that cannot be ignored even if unrecognized
                                                              Comments

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

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

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

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

                                                              A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

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

                                                              The items to be processed for adjudication.

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

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Needed in the processing of institutional claims.

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

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

                                                              ShortBenefit classification
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

                                                              ShortBilling, service, product, or drug code
                                                              Comments

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

                                                              Control1..1
                                                              BindingFor example codes, see USCLSCodes
                                                              (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                                              Allowable service and product codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Necessary to state what was provided or done.

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

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

                                                              ShortService/Product billing modifiers
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              Identifies the program under which this may be recovered.

                                                              ShortProgram the product or service is provided under
                                                              Comments

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

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

                                                              Program specific reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              The number of repetitions of a service or product.

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

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

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

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

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

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

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

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

                                                              ShortPrice scaling factor
                                                              Comments

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

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

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

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

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

                                                              ShortTotal item cost
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              Unique Device Identifiers associated with this line item.

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

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

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

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

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

                                                              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

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

                                                              The adjudication results.

                                                              ShortSubdetail level adjudication details
                                                              Control0..*
                                                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              514. ExplanationOfBenefit.addItem
                                                              Definition

                                                              The first-tier service adjudications for payor added product or service lines.

                                                              ShortInsurer added line items
                                                              Control0..*
                                                              TypeBackboneElement
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

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

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

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

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

                                                              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())
                                                              520. ExplanationOfBenefit.addItem.modifierExtension
                                                              Definition

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

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

                                                              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())
                                                              522. ExplanationOfBenefit.addItem.itemSequence
                                                              Definition

                                                              Claim items which this service line is intended to replace.

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

                                                              Provides references to the claim items.

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

                                                              The sequence number of the details within the claim item which this line is intended to replace.

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

                                                              Provides references to the claim details within the claim item.

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

                                                              The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.

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

                                                              Provides references to the claim sub-details within the claim detail.

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

                                                              The providers who are authorized for the services rendered to the patient.

                                                              ShortAuthorized providers
                                                              Control0..*
                                                              TypeReference(Practitioner, PractitionerRole, Organization)
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

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

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

                                                              ShortBilling, service, product, or drug code
                                                              Comments

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

                                                              Control1..1
                                                              BindingFor example codes, see USCLSCodes
                                                              (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                                              Allowable service and product codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Necessary to state what was provided or done.

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

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

                                                              ShortService/Product billing modifiers
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              Identifies the program under which this may be recovered.

                                                              ShortProgram the product or service is provided under
                                                              Comments

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

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

                                                              Program specific reason codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

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

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

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

                                                              Where the product or service was provided.

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

                                                              Place where the service is rendered.

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

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

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

                                                              The number of repetitions of a service or product.

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

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

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

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

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

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

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

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

                                                              ShortPrice scaling factor
                                                              Comments

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

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

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

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

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

                                                              ShortTotal item cost
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

                                                              ShortAnatomical location
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Allows insurer to validate specific procedures.

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

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

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

                                                              The code for the tooth surface and surface combinations.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Allows insurer to validate specific procedures.

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

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

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

                                                              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

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

                                                              The adjudication results.

                                                              ShortAdded items adjudication
                                                              Control0..*
                                                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              556. ExplanationOfBenefit.addItem.detail
                                                              Definition

                                                              The second-tier service adjudications for payor added services.

                                                              ShortInsurer added line items
                                                              Control0..*
                                                              TypeBackboneElement
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              558. ExplanationOfBenefit.addItem.detail.id
                                                              Definition

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

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

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

                                                              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())
                                                              562. ExplanationOfBenefit.addItem.detail.modifierExtension
                                                              Definition

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

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

                                                              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())
                                                              564. ExplanationOfBenefit.addItem.detail.productOrService
                                                              Definition

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

                                                              ShortBilling, service, product, or drug code
                                                              Comments

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

                                                              Control1..1
                                                              BindingFor example codes, see USCLSCodes
                                                              (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                                              Allowable service and product codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Necessary to state what was provided or done.

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

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

                                                              ShortService/Product billing modifiers
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              The number of repetitions of a service or product.

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

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

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

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

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

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

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

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

                                                              ShortPrice scaling factor
                                                              Comments

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

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

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

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

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

                                                              ShortTotal item cost
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

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

                                                              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

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

                                                              The adjudication results.

                                                              ShortAdded items adjudication
                                                              Control0..*
                                                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              580. ExplanationOfBenefit.addItem.detail.subDetail
                                                              Definition

                                                              The third-tier service adjudications for payor added services.

                                                              ShortInsurer added line items
                                                              Control0..*
                                                              TypeBackboneElement
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              582. ExplanationOfBenefit.addItem.detail.subDetail.id
                                                              Definition

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

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

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

                                                              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())
                                                              586. ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension
                                                              Definition

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

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

                                                              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())
                                                              588. ExplanationOfBenefit.addItem.detail.subDetail.productOrService
                                                              Definition

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

                                                              ShortBilling, service, product, or drug code
                                                              Comments

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

                                                              Control1..1
                                                              BindingFor example codes, see USCLSCodes
                                                              (example to http://hl7.org/fhir/ValueSet/service-uscls)

                                                              Allowable service and product codes.

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

                                                              Necessary to state what was provided or done.

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

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

                                                              ShortService/Product billing modifiers
                                                              Comments

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

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

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

                                                              TypeCodeableConcept
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

                                                              The number of repetitions of a service or product.

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

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

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

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

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

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

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

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

                                                              ShortPrice scaling factor
                                                              Comments

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

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

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

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

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

                                                              ShortTotal item cost
                                                              Comments

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

                                                              Control0..1
                                                              TypeMoney
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Requirements

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

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

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

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

                                                              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

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

                                                              The adjudication results.

                                                              ShortAdded items adjudication
                                                              Control0..*
                                                              TypeSeettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
                                                              Is Modifierfalse
                                                              Summaryfalse
                                                              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                              604. ExplanationOfBenefit.adjudication
                                                              Definition

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

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

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

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

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

                                                                ShortUnique id for inter-element referencing
                                                                Control0..1
                                                                Typestring
                                                                Is Modifierfalse
                                                                XML FormatIn the XML format, this property is represented as an attribute.
                                                                Summaryfalse
                                                                608. ExplanationOfBenefit.adjudication.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())
                                                                610. 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())
                                                                612. 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 PCT GFE Item Adjudication Value Set
                                                                (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()))
                                                                614. ExplanationOfBenefit.adjudication.reason
                                                                Definition

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

                                                                ShortExplanation of adjudication outcome
                                                                Comments

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

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

                                                                Adjudication reason codes.

                                                                TypeCodeableConcept
                                                                Is Modifierfalse
                                                                Summaryfalse
                                                                Requirements

                                                                To support understanding of variance from adjudication expectations.

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

                                                                Monetary amount associated with the category.

                                                                ShortMonetary amount
                                                                Comments

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

                                                                Control0..1
                                                                TypeMoney
                                                                Is Modifierfalse
                                                                Summaryfalse
                                                                Requirements

                                                                Most adjuciation categories convey a monetary amount.

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

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

                                                                ShortNon-monitary value
                                                                Comments

                                                                For example: eligible percentage or co-payment percentage.

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

                                                                Some adjudication categories convey a percentage or a fixed value.

                                                                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                620. 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()))
                                                                622. ExplanationOfBenefit.adjudication:medicalmanagement.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
                                                                624. ExplanationOfBenefit.adjudication:medicalmanagement.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.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                                • value @ url
                                                                • 626. 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: Choice of: string, CodeableConcept)
                                                                  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())
                                                                  628. 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())
                                                                  630. 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
                                                                  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)
                                                                  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()))
                                                                  632. ExplanationOfBenefit.adjudication:medicalmanagement.reason
                                                                  Definition

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

                                                                  ShortExplanation of adjudication outcome
                                                                  Comments

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

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

                                                                  Adjudication reason codes.

                                                                  TypeCodeableConcept
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  To support understanding of variance from adjudication expectations.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  634. 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..0
                                                                  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()))
                                                                  636. 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..0
                                                                  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()))
                                                                  638. 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 Status
                                                                  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()))
                                                                  640. ExplanationOfBenefit.adjudication:billingnetworkstatus.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
                                                                  642. ExplanationOfBenefit.adjudication:billingnetworkstatus.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())
                                                                  644. 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())
                                                                  646. 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
                                                                  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)
                                                                  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()))
                                                                  648. 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 PCT Payer Benefit Payment Status
                                                                  (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()))
                                                                  650. ExplanationOfBenefit.adjudication:billingnetworkstatus.amount
                                                                  Definition

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  654. 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 Status
                                                                  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()))
                                                                  656. ExplanationOfBenefit.adjudication:renderingnetworkstatus.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
                                                                  658. ExplanationOfBenefit.adjudication:renderingnetworkstatus.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())
                                                                  660. 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())
                                                                  662. 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
                                                                  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)
                                                                  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()))
                                                                  664. 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 PCT Payer Benefit Payment Status
                                                                  (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()))
                                                                  666. ExplanationOfBenefit.adjudication:renderingnetworkstatus.amount
                                                                  Definition

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  670. 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 Status
                                                                  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()))
                                                                  672. ExplanationOfBenefit.adjudication:benefitpaymentstatus.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
                                                                  674. ExplanationOfBenefit.adjudication:benefitpaymentstatus.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())
                                                                  676. 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())
                                                                  678. 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
                                                                  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)
                                                                  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()))
                                                                  680. 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 PCT Payer Benefit Payment Status
                                                                  (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()))
                                                                  682. ExplanationOfBenefit.adjudication:benefitpaymentstatus.amount
                                                                  Definition

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  686. 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 Reason
                                                                  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()))
                                                                  688. ExplanationOfBenefit.adjudication:adjustmentreason.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
                                                                  690. ExplanationOfBenefit.adjudication:adjustmentreason.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())
                                                                  692. 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())
                                                                  694. 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
                                                                  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)
                                                                  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()))
                                                                  696. 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 PCT Adjustment 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()))
                                                                  698. ExplanationOfBenefit.adjudication:adjustmentreason.amount
                                                                  Definition

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  702. 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 amount
                                                                  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()))
                                                                  704. ExplanationOfBenefit.adjudication:submitted.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
                                                                  706. ExplanationOfBenefit.adjudication:submitted.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())
                                                                  708. 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())
                                                                  710. 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
                                                                  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)
                                                                  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()))
                                                                  712. ExplanationOfBenefit.adjudication:submitted.reason
                                                                  Definition

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

                                                                  ShortExplanation of adjudication outcome
                                                                  Comments

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

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

                                                                  Adjudication reason codes.

                                                                  TypeCodeableConcept
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  To support understanding of variance from adjudication expectations.

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

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  718. 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 liability
                                                                  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()))
                                                                  720. ExplanationOfBenefit.adjudication:memberliability.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
                                                                  722. ExplanationOfBenefit.adjudication:memberliability.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())
                                                                  724. 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())
                                                                  726. 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
                                                                  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)
                                                                  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()))
                                                                  728. ExplanationOfBenefit.adjudication:memberliability.reason
                                                                  Definition

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

                                                                  ShortExplanation of adjudication outcome
                                                                  Comments

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

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

                                                                  Adjudication reason codes.

                                                                  TypeCodeableConcept
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  To support understanding of variance from adjudication expectations.

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

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  734. 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 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
                                                                  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()))
                                                                  736. ExplanationOfBenefit.adjudication:eligible.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
                                                                  738. ExplanationOfBenefit.adjudication:eligible.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())
                                                                  740. 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())
                                                                  742. 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
                                                                  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)
                                                                  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()))
                                                                  744. ExplanationOfBenefit.adjudication:eligible.reason
                                                                  Definition

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

                                                                  ShortExplanation of adjudication outcome
                                                                  Comments

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

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

                                                                  Adjudication reason codes.

                                                                  TypeCodeableConcept
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  To support understanding of variance from adjudication expectations.

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

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

                                                                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                  750. 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 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
                                                                  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()))
                                                                  752. ExplanationOfBenefit.adjudication:benefit.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
                                                                  754. ExplanationOfBenefit.adjudication:benefit.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())
                                                                  756. 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())
                                                                  758. 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
                                                                  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)
                                                                  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()))
                                                                  760. ExplanationOfBenefit.adjudication:benefit.reason
                                                                  Definition

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

                                                                  ShortExplanation of adjudication outcome
                                                                  Comments

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

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

                                                                  Adjudication reason codes.

                                                                  TypeCodeableConcept
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  To support understanding of variance from adjudication expectations.

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

                                                                  Monetary amount associated with the category.

                                                                  ShortMonetary amount
                                                                  Comments

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

                                                                  Control0..1
                                                                  TypeMoney
                                                                  Is Modifierfalse
                                                                  Summaryfalse
                                                                  Requirements

                                                                  Most adjuciation categories convey a monetary amount.

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

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

                                                                  ShortNon-monitary value
                                                                  Comments

                                                                  For example: eligible percentage or co-payment percentage.

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

                                                                  Some adjudication categories convey a percentage or a fixed value.

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

                                                                  Categorized monetary totals for the adjudication.

                                                                  ShortAdjudication totals
                                                                  Comments

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

                                                                  Control3..*
                                                                  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 areUnordered and Open, and can be differentiated using the following discriminators:
                                                                  • value @ category
                                                                  • 768. ExplanationOfBenefit.total.id
                                                                    Definition

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

                                                                    ShortUnique id for inter-element referencing
                                                                    Control0..1
                                                                    Typestring
                                                                    Is Modifierfalse
                                                                    XML FormatIn the XML format, this property is represented as an attribute.
                                                                    Summaryfalse
                                                                    770. ExplanationOfBenefit.total.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())
                                                                    772. 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())
                                                                    774. 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 PCT Total Value Set
                                                                    (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()))
                                                                    776. 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()))
                                                                    778. ExplanationOfBenefit.total:submitted
                                                                    Slice Namesubmitted
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    ShortTotal provider submitted amount
                                                                    Comments

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

                                                                    Control1..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()))
                                                                    780. ExplanationOfBenefit.total:submitted.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
                                                                    782. ExplanationOfBenefit.total:submitted.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())
                                                                    784. 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())
                                                                    786. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    788. 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()))
                                                                    790. ExplanationOfBenefit.total:memberliability
                                                                    Slice Namememberliability
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

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

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

                                                                    Control1..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()))
                                                                    792. ExplanationOfBenefit.total:memberliability.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
                                                                    794. ExplanationOfBenefit.total:memberliability.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())
                                                                    796. 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())
                                                                    798. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    800. 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()))
                                                                    802. ExplanationOfBenefit.total:eligible
                                                                    Slice Nameeligible
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    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.

                                                                    Control1..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()))
                                                                    804. ExplanationOfBenefit.total:eligible.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
                                                                    806. ExplanationOfBenefit.total:eligible.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())
                                                                    808. 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())
                                                                    810. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    812. 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()))
                                                                    814. ExplanationOfBenefit.total:innetwork
                                                                    Slice Nameinnetwork
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    ShortTotal in network amount - Must include in non-zero total across all AEoBs
                                                                    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()))
                                                                    816. ExplanationOfBenefit.total:innetwork.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
                                                                    818. ExplanationOfBenefit.total:innetwork.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())
                                                                    820. 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())
                                                                    822. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    824. 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()))
                                                                    826. 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 AEoBs
                                                                    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()))
                                                                    828. ExplanationOfBenefit.total:outofnetwork.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
                                                                    830. ExplanationOfBenefit.total:outofnetwork.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())
                                                                    832. 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())
                                                                    834. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    836. 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()))
                                                                    838. ExplanationOfBenefit.total:noncovered
                                                                    Slice Namenoncovered
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    ShortTotal noncovered amount - Must include in non-zero total across all AEoBs
                                                                    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()))
                                                                    840. ExplanationOfBenefit.total:noncovered.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
                                                                    842. ExplanationOfBenefit.total:noncovered.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())
                                                                    844. 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())
                                                                    846. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    848. 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()))
                                                                    850. ExplanationOfBenefit.total:negotiated
                                                                    Slice Namenegotiated
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    ShortTotal negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
                                                                    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()))
                                                                    852. ExplanationOfBenefit.total:negotiated.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
                                                                    854. ExplanationOfBenefit.total:negotiated.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())
                                                                    856. 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())
                                                                    858. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    860. 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()))
                                                                    862. ExplanationOfBenefit.total:benefit
                                                                    Slice Namebenefit
                                                                    Definition

                                                                    Categorized monetary totals for the adjudication.

                                                                    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
                                                                    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()))
                                                                    864. ExplanationOfBenefit.total:benefit.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
                                                                    866. ExplanationOfBenefit.total:benefit.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())
                                                                    868. 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())
                                                                    870. 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
                                                                    BindingUnless not suitable, these codes SHALL be taken from PCT Total Value Set
                                                                    (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.

                                                                    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()))
                                                                    872. 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()))
                                                                    874. ExplanationOfBenefit.payment
                                                                    Definition

                                                                    Payment details for the adjudication of the claim.

                                                                    ShortPayment Details
                                                                    Control0..1
                                                                    TypeBackboneElement
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Needed to convey references to the financial instrument that has been used if payment has been made.

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

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

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

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

                                                                    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())
                                                                    880. ExplanationOfBenefit.payment.modifierExtension
                                                                    Definition

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

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

                                                                    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())
                                                                    882. ExplanationOfBenefit.payment.type
                                                                    Definition

                                                                    Whether this represents partial or complete payment of the benefits payable.

                                                                    ShortPartial or complete payment
                                                                    Control0..1
                                                                    BindingFor example codes, see ExamplePaymentTypeCodes
                                                                    (example to http://hl7.org/fhir/ValueSet/ex-paymenttype)

                                                                    The type (partial, complete) of the payment.

                                                                    TypeCodeableConcept
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    To advise the requestor when the insurer believes all payments to have been completed.

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

                                                                    Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

                                                                    ShortPayment adjustment for non-claim issues
                                                                    Comments

                                                                    Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

                                                                    Control0..1
                                                                    TypeMoney
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    To advise the requestor of adjustments applied to the payment.

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

                                                                    Reason for the payment adjustment.

                                                                    ShortExplanation for the variance
                                                                    Control0..1
                                                                    BindingFor example codes, see PaymentAdjustmentReasonCodes
                                                                    (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason)

                                                                    Payment Adjustment reason codes.

                                                                    TypeCodeableConcept
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Needed to clarify the monetary adjustment.

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

                                                                    Estimated date the payment will be issued or the actual issue date of payment.

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

                                                                    To advise the payee when payment can be expected.

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

                                                                    Benefits payable less any payment adjustment.

                                                                    ShortPayable amount after adjustment
                                                                    Control0..1
                                                                    TypeMoney
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Needed to provide the actual payment amount.

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

                                                                    Issuer's unique identifier for the payment instrument.

                                                                    ShortBusiness identifier for the payment
                                                                    Comments

                                                                    For example: EFT number or check number.

                                                                    NoteThis is a business identifier, not a resource identifier (see discussion)
                                                                    Control0..1
                                                                    TypeIdentifier
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Enable the receiver to reconcile when payment received.

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

                                                                    A code for the form to be used for printing the content.

                                                                    ShortPrinted form identifier
                                                                    Comments

                                                                    May be needed to identify specific jurisdictional forms.

                                                                    Control0..1
                                                                    BindingFor example codes, see Form Codes
                                                                    (example to http://hl7.org/fhir/ValueSet/forms)

                                                                    The forms codes.

                                                                    TypeCodeableConcept
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Needed to specify the specific form used for producing output for this response.

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

                                                                    The actual form, by reference or inclusion, for printing the content or an EOB.

                                                                    ShortPrinted reference or actual form
                                                                    Comments

                                                                    Needed to permit insurers to include the actual form.

                                                                    Control0..1
                                                                    TypeAttachment
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Requirements

                                                                    Needed to include the specific form used for producing output for this response.

                                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                    898. 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 possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
                                                                    Comments

                                                                    These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.

                                                                    Control1..*
                                                                    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()))
                                                                    900. ExplanationOfBenefit.processNote.id
                                                                    Definition

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

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

                                                                    An Extension

                                                                    ShortExtension
                                                                    Control0..*
                                                                    TypeExtension
                                                                    Is Modifierfalse
                                                                    Summaryfalse
                                                                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                                                    SlicingThis element introduces a set of slices on ExplanationOfBenefit.processNote.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                                    • value @ url
                                                                    • 904. 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
                                                                      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())
                                                                      906. 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())
                                                                      908. ExplanationOfBenefit.processNote.number
                                                                      Definition

                                                                      A number to uniquely identify a note entry.

                                                                      ShortNote instance identifier
                                                                      Control0..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 from adjudications.

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

                                                                      The business purpose of the note text.

                                                                      Shortdisplay | print | printoper
                                                                      Control0..1
                                                                      BindingThe codes SHALL be taken from NoteType
                                                                      (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)

                                                                      The presentation types of notes.

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

                                                                      To convey the expectation for when the text is used.

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

                                                                      The explanation or description associated with the processing.

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

                                                                      Required to provide human readable explanation.

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

                                                                      A code to define the language used in the text of the note.

                                                                      ShortLanguage of the text
                                                                      Comments

                                                                      Only required if the language is different from the resource language.

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

                                                                      A human language.

                                                                      Additional BindingsPurpose
                                                                      AllLanguagesMax Binding
                                                                      TypeCodeableConcept
                                                                      Is Modifierfalse
                                                                      Summaryfalse
                                                                      Requirements

                                                                      Note text may vary from the resource defined language.

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

                                                                      The term of the benefits documented in this response.

                                                                      ShortWhen the benefits are applicable
                                                                      Comments

                                                                      Not applicable when use=claim.

                                                                      Control1..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()))
                                                                      918. ExplanationOfBenefit.benefitBalance
                                                                      Definition

                                                                      Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.

                                                                      ShortEstimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
                                                                      Control1..*
                                                                      TypeBackboneElement
                                                                      Is Modifierfalse
                                                                      Summaryfalse
                                                                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                      920. ExplanationOfBenefit.benefitBalance.id
                                                                      Definition

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

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

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

                                                                      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())
                                                                      924. 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())
                                                                      926. 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 PCT benefitBalance.category codes
                                                                      (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()))
                                                                      928. ExplanationOfBenefit.benefitBalance.category.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
                                                                      930. ExplanationOfBenefit.benefitBalance.category.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.benefitBalance.category.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                                      • value @ url
                                                                      • 932. ExplanationOfBenefit.benefitBalance.category.coding
                                                                        Definition

                                                                        A reference to a code defined by a terminology system.

                                                                        ShortCode defined by a terminology system
                                                                        Comments

                                                                        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

                                                                        Control0..*
                                                                        TypeCoding
                                                                        Is Modifierfalse
                                                                        Summarytrue
                                                                        Requirements

                                                                        Allows for alternative encodings within a code system, and translations to other code systems.

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

                                                                        A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                                                                        ShortPlain text representation of the concept
                                                                        Comments

                                                                        Very often the text is the same as a displayName of one of the codings.

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

                                                                        The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

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

                                                                        True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.

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

                                                                        Needed to identify items that are specifically excluded from the coverage.

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

                                                                        A short name or tag for the benefit.

                                                                        ShortShort name for the benefit
                                                                        Comments

                                                                        For example: MED01, or DENT2.

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

                                                                        Required to align with other plan names.

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

                                                                        A richer description of the benefit or services covered.

                                                                        ShortDescription of the benefit or services covered
                                                                        Comments

                                                                        For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.

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

                                                                        Needed for human readable reference.

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

                                                                        Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.

                                                                        ShortIn or out of network
                                                                        Control0..1
                                                                        BindingFor example codes, see NetworkTypeCodes
                                                                        (example to http://hl7.org/fhir/ValueSet/benefit-network)

                                                                        Code to classify in or out of network services.

                                                                        TypeCodeableConcept
                                                                        Is Modifierfalse
                                                                        Summaryfalse
                                                                        Requirements

                                                                        Needed as in or out of network providers are treated differently under the coverage.

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

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

                                                                        ShortIndividual or family
                                                                        Control1..1
                                                                        BindingThe codes SHALL be taken from UnitTypeCodes
                                                                        (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()))
                                                                        946. ExplanationOfBenefit.benefitBalance.term
                                                                        Definition

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

                                                                        ShortAnnual or lifetime
                                                                        Control1..1
                                                                        BindingThe codes SHALL be taken from BenefitTermCodes
                                                                        (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()))
                                                                        948. ExplanationOfBenefit.benefitBalance.financial
                                                                        Definition

                                                                        Benefits Used to date.

                                                                        ShortBenefit Summary
                                                                        Control1..*
                                                                        TypeBackboneElement
                                                                        Is Modifierfalse
                                                                        Summaryfalse
                                                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                        950. ExplanationOfBenefit.benefitBalance.financial.id
                                                                        Definition

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

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

                                                                        An Extension

                                                                        ShortExtension
                                                                        Control0..*
                                                                        TypeExtension
                                                                        Is Modifierfalse
                                                                        Summaryfalse
                                                                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                                                                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                                                                        SlicingThis element introduces a set of slices on ExplanationOfBenefit.benefitBalance.financial.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                                                                        • value @ url
                                                                        • 954. 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
                                                                          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())
                                                                          956. 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())
                                                                          958. 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 PCT Financial Type Value Set
                                                                          (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()))
                                                                          960. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
                                                                          Definition

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

                                                                          ShortBenefits allowed
                                                                          Control1..1
                                                                          TypeChoice of: unsignedInt, Money
                                                                          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                                                          Is Modifierfalse
                                                                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                                          Must Supporttrue
                                                                          Must Support TypesChoice of: unsignedInt, Money
                                                                          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()))
                                                                          962. ExplanationOfBenefit.benefitBalance.financial.used[x]
                                                                          Definition

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

                                                                          ShortBenefits used
                                                                          Control1..1
                                                                          TypeChoice of: unsignedInt, Money
                                                                          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                                                                          Is Modifierfalse
                                                                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                                                                          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()))