Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions
Page standards status: Trial-use | Maturity Level: 2 |
Definitions for the davinci-pct-aeob resource profile.
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |
Invariants | pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() )pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() )pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() ) |
2. ExplanationOfBenefit.extension | |
Control | 1..? |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
4. ExplanationOfBenefit.extension:gfeReference | |
Slice Name | gfeReference |
Short | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. |
Control | 1..* |
Type | Extension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle)) |
6. ExplanationOfBenefit.extension:serviceDescription | |
Slice Name | serviceDescription |
Control | 0..1 This element is affected by the following invariants: pct-aeob-1 |
Type | Extension(Service Description) (Extension Type: string) |
Must Support | true |
8. ExplanationOfBenefit.extension:outOfNetworkProviderInfo | |
Slice Name | outOfNetworkProviderInfo |
Control | 0..1 |
Type | Extension(In Network Provider Options Link) (Extension Type: url) |
Must Support | true |
10. ExplanationOfBenefit.identifier | |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 1..? |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
12. ExplanationOfBenefit.identifier:INTER | |
Slice Name | INTER |
Short | Intermediary System Identifier |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 0..* |
14. ExplanationOfBenefit.identifier:INTER.type | |
Control | 1..? |
Pattern Value | { |
16. ExplanationOfBenefit.identifier:uniqueclaimid | |
Slice Name | uniqueclaimid |
Short | Unique Claim ID |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 1..1 |
18. ExplanationOfBenefit.identifier:uniqueclaimid.type | |
Control | 1..? |
Pattern Value | { |
20. ExplanationOfBenefit.type | |
Binding | The codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS ) |
22. ExplanationOfBenefit.use | |
Pattern Value | predetermination |
24. ExplanationOfBenefit.patient | |
Type | Reference(HRex Patient Demographics) |
26. ExplanationOfBenefit.created | |
Short | The date and time this estimate was calculated. |
Comments | The date and time this estimate was calculated based on what was known at that point in time. |
28. ExplanationOfBenefit.insurer | |
Type | Reference(PCT Organization) |
30. ExplanationOfBenefit.provider | |
Type | Reference(PCT Practitioner, PCT Organization) |
32. ExplanationOfBenefit.priority | |
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to http://hl7.org/fhir/ValueSet/process-priority ) |
Must Support | true |
34. ExplanationOfBenefit.claim | |
Control | 1..? |
36. ExplanationOfBenefit.claim.identifier | |
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values). |
Short | GFE identifier of the originally submitted claim |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 1..? |
38. ExplanationOfBenefit.claim.identifier.system | |
Must Support | true |
40. ExplanationOfBenefit.claim.identifier.value | |
Control | 1..? |
42. ExplanationOfBenefit.insurance | |
44. ExplanationOfBenefit.insurance.coverage | |
Type | Reference(PCT Coverage) |
46. ExplanationOfBenefit.item | |
Control | 1..? |
48. ExplanationOfBenefit.item.extension | |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
50. ExplanationOfBenefit.item.extension:serviceDescription | |
Slice Name | serviceDescription |
Control | 0..1 This element is affected by the following invariants: pct-aeob-1 |
Type | Extension(Service Description) (Extension Type: string) |
Must Support | true |
52. ExplanationOfBenefit.item.revenue | |
Binding | The codes SHALL be taken from PCT GFE NUBC Revenue Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemRevenueVS ) |
54. ExplanationOfBenefit.item.productOrService | |
Binding | The codes SHALL be taken from Claim Medical Product or Service Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes ) |
56. ExplanationOfBenefit.item.modifier | |
Control | 0..4 |
Binding | The codes SHALL be taken from PCT GFE Item CPT - HCPCS Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS ) |
Must Support | true |
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 |
Short | This is the planned or estimated date(s)s of service |
Control | 1..? |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
60. ExplanationOfBenefit.item.quantity | |
Must Support | true |
62. ExplanationOfBenefit.item.adjudication | |
Control | 1..? |
Must Support | true |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
64. ExplanationOfBenefit.item.adjudication.category | |
Binding | Unless 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 Name | medicalmanagement |
Control | 0..* |
Must Support | true |
68. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension | |
Control | 1..? |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
70. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension:subjectToMedicalMgmt | |
Slice Name | subjectToMedicalMgmt |
Control | 1..1 |
Type | Extension(Subject To Medical Management) (Extension Type: Choice of: string, CodeableConcept) |
72. ExplanationOfBenefit.item.adjudication:medicalmanagement.category | |
Pattern Value | { |
74. ExplanationOfBenefit.item.adjudication:medicalmanagement.amount | |
Control | 0..0 |
76. ExplanationOfBenefit.item.adjudication:medicalmanagement.value | |
Control | 0..0 |
78. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus | |
Slice Name | benefitpaymentstatus |
Short | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. |
Control | 0..1 |
Must Support | true |
80. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | |
Pattern Value | { |
82. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | |
Binding | The 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 Name | adjustmentreason |
Short | Adjustment Reason |
Control | 0..* |
Must Support | true |
86. ExplanationOfBenefit.item.adjudication:adjustmentreason.category | |
Pattern Value | { |
88. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | |
Binding | The 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 Name | submitted |
Short | Provider submitted amount |
Control | 0..1 |
Must Support | true |
92. ExplanationOfBenefit.item.adjudication:submitted.category | |
Pattern Value | { |
94. ExplanationOfBenefit.item.adjudication:memberliability | |
Slice Name | memberliability |
Short | Member liability |
Comments | $0 is an acceptable value |
Control | 0..1 |
Must Support | true |
96. ExplanationOfBenefit.item.adjudication:memberliability.category | |
Pattern Value | { |
98. ExplanationOfBenefit.item.adjudication:eligible | |
Slice Name | eligible |
Short | Eligible 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. |
Control | 0..1 |
Must Support | true |
100. ExplanationOfBenefit.item.adjudication:eligible.category | |
Pattern Value | { |
102. ExplanationOfBenefit.item.adjudication:benefit | |
Slice Name | benefit |
Short | Benefit 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. |
Control | 0..1 |
Must Support | true |
104. ExplanationOfBenefit.item.adjudication:benefit.category | |
Pattern Value | { |
106. ExplanationOfBenefit.adjudication | |
Type | BackboneElement |
Must Support | true |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
108. ExplanationOfBenefit.adjudication.category | |
Binding | Unless 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 Name | medicalmanagement |
Control | 0..* |
Type | BackboneElement |
Must Support | true |
112. ExplanationOfBenefit.adjudication:medicalmanagement.extension | |
Control | 1..? |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
114. ExplanationOfBenefit.adjudication:medicalmanagement.extension:subjectToMedicalMgmt | |
Slice Name | subjectToMedicalMgmt |
Control | 1..1 |
Type | Extension(Subject To Medical Management) (Extension Type: Choice of: string, CodeableConcept) |
116. ExplanationOfBenefit.adjudication:medicalmanagement.category | |
Pattern Value | { |
118. ExplanationOfBenefit.adjudication:medicalmanagement.amount | |
Control | 0..0 |
120. ExplanationOfBenefit.adjudication:medicalmanagement.value | |
Control | 0..0 |
122. ExplanationOfBenefit.adjudication:billingnetworkstatus | |
Slice Name | billingnetworkstatus |
Short | Billing Provider Network Status |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
124. ExplanationOfBenefit.adjudication:billingnetworkstatus.category | |
Pattern Value | { |
126. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | |
Binding | The 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 Name | renderingnetworkstatus |
Short | Rendering Provider Network Status |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
130. ExplanationOfBenefit.adjudication:renderingnetworkstatus.category | |
Pattern Value | { |
132. ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | |
Binding | The 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 Name | benefitpaymentstatus |
Short | Benefit Payment Status |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
136. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | |
Pattern Value | { |
138. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | |
Binding | The 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 Name | adjustmentreason |
Short | Adjustment Reason |
Control | 0..* |
Type | BackboneElement |
Must Support | true |
142. ExplanationOfBenefit.adjudication:adjustmentreason.category | |
Pattern Value | { |
144. ExplanationOfBenefit.adjudication:adjustmentreason.reason | |
Binding | The codes SHALL be taken from PCT Adjustment Reason (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAdjustmentReasonVS ) |
146. ExplanationOfBenefit.adjudication:submitted | |
Slice Name | submitted |
Short | Provider submitted amount |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
148. ExplanationOfBenefit.adjudication:submitted.category | |
Pattern Value | { |
150. ExplanationOfBenefit.adjudication:memberliability | |
Slice Name | memberliability |
Short | Member liability |
Comments | $0 is an acceptable value |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
152. ExplanationOfBenefit.adjudication:memberliability.category | |
Pattern Value | { |
154. ExplanationOfBenefit.adjudication:eligible | |
Slice Name | eligible |
Short | Eligible 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. |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
156. ExplanationOfBenefit.adjudication:eligible.category | |
Pattern Value | { |
158. ExplanationOfBenefit.adjudication:benefit | |
Slice Name | benefit |
Short | Benefit 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. |
Control | 0..1 |
Type | BackboneElement |
Must Support | true |
160. ExplanationOfBenefit.adjudication:benefit.category | |
Pattern Value | { |
162. ExplanationOfBenefit.total | |
Control | 1..? |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.total . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
164. ExplanationOfBenefit.total.category | |
Binding | Unless not suitable, these codes SHALL be taken from PCT Total Value Set (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal ) |
Must Support | true |
166. ExplanationOfBenefit.total:submitted | |
Slice Name | submitted |
Short | Total provider submitted amount |
Control | 1..1 |
Must Support | true |
168. ExplanationOfBenefit.total:submitted.category | |
Pattern Value | { |
170. ExplanationOfBenefit.total:memberliability | |
Slice Name | memberliability |
Short | Total member liability - Must include in non-zero total across all AEoBs |
Control | 0..1 |
Must Support | true |
172. ExplanationOfBenefit.total:memberliability.category | |
Pattern Value | { |
174. ExplanationOfBenefit.total:innetwork | |
Slice Name | innetwork |
Short | Total in network amount - Must include in non-zero total across all AEoBs |
Control | 0..1 |
Must Support | true |
176. ExplanationOfBenefit.total:innetwork.category | |
Pattern Value | { |
178. ExplanationOfBenefit.total:outofnetwork | |
Slice Name | outofnetwork |
Short | Total out of network amount - Must include in non-zero total across all AEoBs |
Control | 0..1 |
Must Support | true |
180. ExplanationOfBenefit.total:outofnetwork.category | |
Pattern Value | { |
182. ExplanationOfBenefit.total:noncovered | |
Slice Name | noncovered |
Short | Total noncovered amount - Must include in non-zero total across all AEoBs |
Control | 0..1 |
Must Support | true |
184. ExplanationOfBenefit.total:noncovered.category | |
Pattern Value | { |
186. ExplanationOfBenefit.total:negotiated | |
Slice Name | negotiated |
Short | Total negotiated amount - Must include in non-zero total across all AEoBs |
Control | 0..1 |
Must Support | true |
188. ExplanationOfBenefit.total:negotiated.category | |
Pattern Value | { |
190. ExplanationOfBenefit.total:eligible | |
Slice Name | eligible |
Short | Total 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. |
Control | 0..1 |
Must Support | true |
192. ExplanationOfBenefit.total:eligible.category | |
Pattern Value | { |
194. ExplanationOfBenefit.total:benefit | |
Slice Name | benefit |
Short | Total 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. |
Control | 0..1 |
Must Support | true |
196. ExplanationOfBenefit.total:benefit.category | |
Pattern Value | { |
198. ExplanationOfBenefit.processNote | |
Short | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible |
Control | 1..? |
200. ExplanationOfBenefit.processNote.extension | |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.processNote.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
202. ExplanationOfBenefit.processNote.extension:processNoteClass | |
Slice Name | processNoteClass |
Control | 0..1 |
Type | Extension(ProcessNote Class) (Extension Type: CodeableConcept) |
204. ExplanationOfBenefit.benefitPeriod | |
Control | 1..? |
206. ExplanationOfBenefit.benefitBalance | |
Control | 1..? |
208. ExplanationOfBenefit.benefitBalance.category | |
Binding | The codes SHALL be taken from PCT benefitBalance.category codes (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTBenefitBalanceCategoryVS ) |
210. ExplanationOfBenefit.benefitBalance.unit | |
Control | 1..? |
Binding | The codes SHALL be taken from UnitTypeCodes (required to http://hl7.org/fhir/ValueSet/benefit-unit ) |
212. ExplanationOfBenefit.benefitBalance.term | |
Control | 1..? |
Binding | The codes SHALL be taken from BenefitTermCodes (required to http://hl7.org/fhir/ValueSet/benefit-term ) |
214. ExplanationOfBenefit.benefitBalance.financial | |
Control | 1..? |
216. ExplanationOfBenefit.benefitBalance.financial.extension | |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.benefitBalance.financial.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
218. ExplanationOfBenefit.benefitBalance.financial.extension:remaining | |
Slice Name | remaining |
Control | 0..1 |
Type | Extension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money) |
Must Support | true |
220. ExplanationOfBenefit.benefitBalance.financial.type | |
Binding | The codes SHALL be taken from PCT Financial Type Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTFinancialTypeVS ) |
222. ExplanationOfBenefit.benefitBalance.financial.allowed[x] | |
Control | 1..? |
Type | Choice of: unsignedInt, Money, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | Choice of: unsignedInt, Money, string |
224. ExplanationOfBenefit.benefitBalance.financial.used[x] | |
Control | 1..? |
Type | Choice of: unsignedInt, Money |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | Choice of: unsignedInt, Money |
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided. |
Short | Explanation of Benefit resource |
Control | 0..* |
Is Modifier | false |
Summary | false |
Alternate Names | EOB |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) ( extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() )pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() )pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() ) |
2. ExplanationOfBenefit.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. ExplanationOfBenefit.extension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 10..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
6. ExplanationOfBenefit.extension:gfeReference | |
Slice Name | gfeReference |
Definition | This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB. |
Short | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. |
Control | 1..* This element is affected by the following invariants: ele-1 |
Type | Extension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle)) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
8. ExplanationOfBenefit.extension:serviceDescription | |
Slice Name | serviceDescription |
Definition | This extension is used to communicate a plain language description of the procedure, product, or service. |
Short | Service Description |
Control | 0..1 This element is affected by the following invariants: ele-1, pct-aeob-1 |
Type | Extension(Service Description) (Extension Type: string) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
10. ExplanationOfBenefit.extension:outOfNetworkProviderInfo | |
Slice Name | outOfNetworkProviderInfo |
Definition | This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services. |
Short | In Network Provider Options Link |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Extension(In Network Provider Options Link) (Extension Type: url) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )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). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
14. ExplanationOfBenefit.identifier | |
Definition | A unique identifier assigned to this explanation of benefit. |
Short | Business Identifier for the resource |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 10..* |
Type | Identifier |
Is Modifier | false |
Summary | false |
Requirements | Allows EOBs to be distinguished and referenced. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
16. ExplanationOfBenefit.identifier:INTER | |
Slice Name | INTER |
Definition | A unique identifier assigned to this explanation of benefit. |
Short | Intermediary System IdentifierBusiness Identifier for the resource |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 0..* |
Type | Identifier |
Is Modifier | false |
Summary | false |
Requirements | Allows EOBs to be distinguished and referenced. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. ExplanationOfBenefit.identifier:INTER.use | |
Definition | The purpose of this identifier. |
Short | usual | official | temp | secondary | old (If known) |
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
Control | 0..1 |
Binding | The 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 . |
Type | code |
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. ExplanationOfBenefit.identifier:INTER.type | |
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. |
Short | Description 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. |
Control | 10..1 |
Binding | Unless 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. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Allows users to make use of identifiers when the identifier system is not known. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. ExplanationOfBenefit.identifier:uniqueclaimid | |
Slice Name | uniqueclaimid |
Definition | A unique identifier assigned to this explanation of benefit. |
Short | Unique Claim IDBusiness Identifier for the resource |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 10..1* |
Type | Identifier |
Is Modifier | false |
Summary | false |
Requirements | Allows EOBs to be distinguished and referenced. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
24. ExplanationOfBenefit.identifier:uniqueclaimid.use | |
Definition | The purpose of this identifier. |
Short | usual | official | temp | secondary | old (If known) |
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
Control | 0..1 |
Binding | The 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 . |
Type | code |
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. ExplanationOfBenefit.identifier:uniqueclaimid.type | |
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. |
Short | Description 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. |
Control | 10..1 |
Binding | Unless 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. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Allows users to make use of identifiers when the identifier system is not known. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
28. ExplanationOfBenefit.status | |
Definition | The status of the resource instance. |
Short | active | cancelled | draft | entered-in-error |
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from 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. |
Type | code |
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
30. ExplanationOfBenefit.type | |
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. |
Short | Category or discipline |
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements. |
Control | 1..1 |
Binding | The codes SHALL be taken from Unless not suitable, these codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Sethttp://hl7.org/fhir/ValueSet/claim-type (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
32. ExplanationOfBenefit.use | |
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. |
Short | claim | preauthorization | predetermination |
Control | 1..1 |
Binding | The 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. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | This element is required to understand the nature of the request for adjudication. |
Pattern Value | predetermination |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
34. ExplanationOfBenefit.patient | |
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. |
Short | The recipient of the products and services |
Control | 1..1 |
Type | Reference(HRex Patient Demographics, Patient) |
Is Modifier | false |
Summary | true |
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
36. ExplanationOfBenefit.created | |
Definition | The date this resource was created. |
Short | The 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. |
Control | 1..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
38. ExplanationOfBenefit.insurer | |
Definition | The party responsible for authorization, adjudication and reimbursement. |
Short | Party responsible for reimbursement |
Control | 1..1 |
Type | Reference(PCT Organization, Organization) |
Is Modifier | false |
Summary | true |
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
40. ExplanationOfBenefit.provider | |
Definition | The provider which is responsible for the claim, predetermination or preauthorization. |
Short | Party responsible for the claim |
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. |
Control | 1..1 |
Type | Reference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization) |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
42. ExplanationOfBenefit.priority | |
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. |
Short | Desired processing urgency |
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. |
Control | 0..1 |
Binding | The codes SHALL be taken from For example codes, see ProcessPriorityCodeshttp://terminology.hl7.org/CodeSystem/processpriority (required to http://hl7.org/fhir/ValueSet/process-priority ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
44. ExplanationOfBenefit.claim | |
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. |
Short | Claim reference |
Control | 10..1 |
Type | Reference(Claim) |
Is Modifier | false |
Summary | false |
Requirements | To provide a link to the original adjudication request. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
46. ExplanationOfBenefit.claim.identifier | |
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values). An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. |
Short | GFE 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). |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 10..1 |
Type | Identifier |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
48. ExplanationOfBenefit.claim.identifier.use | |
Definition | The purpose of this identifier. |
Short | usual | official | temp | secondary | old (If known) |
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. |
Control | 0..1 |
Binding | The 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 . |
Type | code |
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
50. ExplanationOfBenefit.claim.identifier.system | |
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. |
Short | The namespace for the identifier value |
Comments | Identifier.system is always case sensitive. |
Control | 0..1 |
Type | uri |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. |
Example | <br/><b>General</b>:http://www.acme.com/identifiers/patient |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
52. ExplanationOfBenefit.claim.identifier.value | |
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. |
Short | The 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. |
Control | 10..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Example | <br/><b>General</b>:123456 |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
54. ExplanationOfBenefit.outcome | |
Definition | The outcome of the claim, predetermination, or preauthorization processing. |
Short | queued | complete | error | partial |
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). |
Control | 1..1 |
Binding | The codes SHALL be taken from 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. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | To advise the requestor of an overall processing outcome. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
56. ExplanationOfBenefit.insurance | |
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim. |
Short | Patient insurance information |
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. |
Control | 1..* |
Type | BackboneElement |
Is Modifier | false |
Summary | true |
Requirements | At least one insurer is required for a claim to be a claim. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
58. ExplanationOfBenefit.insurance.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
60. ExplanationOfBenefit.insurance.focal | |
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. |
Short | Coverage to be used for adjudication |
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. |
Control | 1..1 |
Type | boolean |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | To identify which coverage in the list is being used to adjudicate this claim. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
62. ExplanationOfBenefit.insurance.coverage | |
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. |
Short | Insurance information |
Control | 1..1 |
Type | Reference(PCT Coverage, Coverage) |
Is Modifier | false |
Summary | true |
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
64. ExplanationOfBenefit.item | |
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. |
Short | Product or service provided |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Requirements | The items to be processed for adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
66. ExplanationOfBenefit.item.extension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
68. ExplanationOfBenefit.item.extension:serviceDescription | |
Slice Name | serviceDescription |
Definition | This extension is used to communicate a plain language description of the procedure, product, or service. |
Short | Service Description |
Control | 0..1 This element is affected by the following invariants: ele-1, pct-aeob-1 |
Type | Extension(Service Description) (Extension Type: string) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
70. ExplanationOfBenefit.item.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
72. ExplanationOfBenefit.item.sequence | |
Definition | A number to uniquely identify item entries. |
Short | Item instance identifier |
Control | 1..1 |
Type | positiveInt |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
74. ExplanationOfBenefit.item.revenue | |
Definition | The type of revenue or cost center providing the product and/or service. |
Short | Revenue or cost center code |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed in the processing of institutional claims. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
76. ExplanationOfBenefit.item.productOrService | |
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. |
Short | Billing, service, product, or drug code |
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
Control | 1..1 |
Binding | The codes SHALL be taken from For example codes, see Claim Medical Product or Service Value Sethttp://hl7.org/fhir/ValueSet/service-uscls (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Necessary to state what was provided or done. |
Alternate Names | Drug Code, Bill Code, Service Code |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
78. ExplanationOfBenefit.item.modifier | |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Short | Product or service billing modifiers |
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. |
Control | 0..4* |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
80. ExplanationOfBenefit.item.serviced[x] | |
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication The date or dates when the service or product was supplied, performed or completed. |
Short | This is the planned or estimated date(s)s of serviceDate or dates of service or product delivery |
Control | 10..1 |
Type | Choice of: date, Period |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
82. ExplanationOfBenefit.item.quantity | |
Definition | The number of repetitions of a service or product. |
Short | Count of products or services |
Control | 0..1 |
Type | Quantity(SimpleQuantity) |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Required when the product or service code does not convey the quantity provided. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
84. ExplanationOfBenefit.item.adjudication | |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Adjudication details |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
86. ExplanationOfBenefit.item.adjudication.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
88. ExplanationOfBenefit.item.adjudication.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
90. ExplanationOfBenefit.item.adjudication:medicalmanagement | |
Slice Name | medicalmanagement |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Adjudication details |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
92. ExplanationOfBenefit.item.adjudication: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. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 10..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.item.adjudication.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
94. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension:subjectToMedicalMgmt | |
Slice Name | subjectToMedicalMgmt |
Definition | This extension is used to provide a reason to explain how the estimate may change subject to medical management. |
Short | Subject To Medical Management |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Type | Extension(Subject To Medical Management) (Extension Type: Choice of: string, CodeableConcept) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
96. ExplanationOfBenefit.item.adjudication: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). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
98. ExplanationOfBenefit.item.adjudication: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. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
100. ExplanationOfBenefit.item.adjudication:medicalmanagement.amount | |
Definition | Monetary amount associated with the category. |
Short | Monetary amount |
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. |
Control | 0..01 |
Type | Money |
Is Modifier | false |
Summary | false |
Requirements | Most adjuciation categories convey a monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
102. ExplanationOfBenefit.item.adjudication:medicalmanagement.value | |
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. |
Short | Non-monitary value |
Comments | For example: eligible percentage or co-payment percentage. |
Control | 0..01 |
Type | decimal |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Some adjudication categories convey a percentage or a fixed value. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
104. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus | |
Slice Name | benefitpaymentstatus |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.Adjudication details |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
106. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
108. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
110. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
112. ExplanationOfBenefit.item.adjudication:adjustmentreason | |
Slice Name | adjustmentreason |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Adjustment ReasonAdjudication details |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
114. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
116. ExplanationOfBenefit.item.adjudication:adjustmentreason.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
118. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
120. ExplanationOfBenefit.item.adjudication:submitted | |
Slice Name | submitted |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Provider submitted amountAdjudication details |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
122. ExplanationOfBenefit.item.adjudication:submitted.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
124. ExplanationOfBenefit.item.adjudication:submitted.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
126. ExplanationOfBenefit.item.adjudication:memberliability | |
Slice Name | memberliability |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Member liabilityAdjudication details |
Comments | $0 is an acceptable value |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
128. ExplanationOfBenefit.item.adjudication:memberliability.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
130. ExplanationOfBenefit.item.adjudication:memberliability.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
132. ExplanationOfBenefit.item.adjudication:eligible | |
Slice Name | eligible |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Eligible 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
134. ExplanationOfBenefit.item.adjudication:eligible.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
136. ExplanationOfBenefit.item.adjudication:eligible.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
138. ExplanationOfBenefit.item.adjudication:benefit | |
Slice Name | benefit |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Short | Benefit 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
140. ExplanationOfBenefit.item.adjudication:benefit.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
142. ExplanationOfBenefit.item.adjudication:benefit.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
144. ExplanationOfBenefit.adjudication | |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Header-level adjudication |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
146. ExplanationOfBenefit.adjudication.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
148. ExplanationOfBenefit.adjudication.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
150. ExplanationOfBenefit.adjudication:medicalmanagement | |
Slice Name | medicalmanagement |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Header-level adjudication |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
152. ExplanationOfBenefit.adjudication: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. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 10..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.adjudication.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
154. ExplanationOfBenefit.adjudication:medicalmanagement.extension:subjectToMedicalMgmt | |
Slice Name | subjectToMedicalMgmt |
Definition | This extension is used to provide a reason to explain how the estimate may change subject to medical management. |
Short | Subject To Medical Management |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Type | Extension(Subject To Medical Management) (Extension Type: Choice of: string, CodeableConcept) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
156. ExplanationOfBenefit.adjudication: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). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
158. ExplanationOfBenefit.adjudication: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. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
160. ExplanationOfBenefit.adjudication:medicalmanagement.amount | |
Definition | Monetary amount associated with the category. |
Short | Monetary amount |
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable. |
Control | 0..01 |
Type | Money |
Is Modifier | false |
Summary | false |
Requirements | Most adjuciation categories convey a monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
162. ExplanationOfBenefit.adjudication:medicalmanagement.value | |
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. |
Short | Non-monitary value |
Comments | For example: eligible percentage or co-payment percentage. |
Control | 0..01 |
Type | decimal |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Some adjudication categories convey a percentage or a fixed value. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
164. ExplanationOfBenefit.adjudication:billingnetworkstatus | |
Slice Name | billingnetworkstatus |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Billing Provider Network StatusHeader-level adjudication |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
166. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
168. ExplanationOfBenefit.adjudication:billingnetworkstatus.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
170. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
172. ExplanationOfBenefit.adjudication:renderingnetworkstatus | |
Slice Name | renderingnetworkstatus |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Rendering Provider Network StatusHeader-level adjudication |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
174. ExplanationOfBenefit.adjudication:renderingnetworkstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
176. ExplanationOfBenefit.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. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
178. ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
180. ExplanationOfBenefit.adjudication:benefitpaymentstatus | |
Slice Name | benefitpaymentstatus |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Benefit Payment StatusHeader-level adjudication |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
182. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
184. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
186. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
188. ExplanationOfBenefit.adjudication:adjustmentreason | |
Slice Name | adjustmentreason |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Adjustment ReasonHeader-level adjudication |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
190. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
192. ExplanationOfBenefit.adjudication:adjustmentreason.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
194. ExplanationOfBenefit.adjudication:adjustmentreason.reason | |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Short | Explanation of adjudication outcome |
Comments | For example, may indicate that the funds for this benefit type have been exhausted. |
Control | 0..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | To support understanding of variance from adjudication expectations. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
196. ExplanationOfBenefit.adjudication:submitted | |
Slice Name | submitted |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Provider submitted amountHeader-level adjudication |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
198. ExplanationOfBenefit.adjudication:submitted.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
200. ExplanationOfBenefit.adjudication:submitted.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
202. ExplanationOfBenefit.adjudication:memberliability | |
Slice Name | memberliability |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Member liabilityHeader-level adjudication |
Comments | $0 is an acceptable value |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
204. ExplanationOfBenefit.adjudication:memberliability.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
206. ExplanationOfBenefit.adjudication:memberliability.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
208. ExplanationOfBenefit.adjudication:eligible | |
Slice Name | eligible |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Eligible 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
210. ExplanationOfBenefit.adjudication:eligible.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
212. ExplanationOfBenefit.adjudication:eligible.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
214. ExplanationOfBenefit.adjudication:benefit | |
Slice Name | benefit |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Short | Benefit 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
216. ExplanationOfBenefit.adjudication:benefit.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
218. ExplanationOfBenefit.adjudication:benefit.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
220. ExplanationOfBenefit.total | |
Definition | Categorized monetary totals for the adjudication. |
Short | Adjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.total . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
222. ExplanationOfBenefit.total.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
224. ExplanationOfBenefit.total.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see PCT Total Value Sethttp://hl7.org/fhir/ValueSet/adjudication (extensible to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTTotal ) |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
226. ExplanationOfBenefit.total.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
228. ExplanationOfBenefit.total:submitted | |
Slice Name | submitted |
Definition | Categorized monetary totals for the adjudication. |
Short | Total provider submitted amountAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 10..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
230. ExplanationOfBenefit.total:submitted.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
232. ExplanationOfBenefit.total:submitted.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
234. ExplanationOfBenefit.total:submitted.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
236. ExplanationOfBenefit.total:memberliability | |
Slice Name | memberliability |
Definition | Categorized monetary totals for the adjudication. |
Short | Total member liability - Must include in non-zero total across all AEoBsAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
238. ExplanationOfBenefit.total:memberliability.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
240. ExplanationOfBenefit.total:memberliability.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
242. ExplanationOfBenefit.total:memberliability.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
244. ExplanationOfBenefit.total:innetwork | |
Slice Name | innetwork |
Definition | Categorized monetary totals for the adjudication. |
Short | Total in network amount - Must include in non-zero total across all AEoBsAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
246. ExplanationOfBenefit.total:innetwork.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
248. ExplanationOfBenefit.total:innetwork.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
250. ExplanationOfBenefit.total:innetwork.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
252. ExplanationOfBenefit.total:outofnetwork | |
Slice Name | outofnetwork |
Definition | Categorized monetary totals for the adjudication. |
Short | Total out of network amount - Must include in non-zero total across all AEoBsAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
254. ExplanationOfBenefit.total:outofnetwork.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
256. ExplanationOfBenefit.total:outofnetwork.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
258. ExplanationOfBenefit.total:outofnetwork.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
260. ExplanationOfBenefit.total:noncovered | |
Slice Name | noncovered |
Definition | Categorized monetary totals for the adjudication. |
Short | Total noncovered amount - Must include in non-zero total across all AEoBsAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
262. ExplanationOfBenefit.total:noncovered.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
264. ExplanationOfBenefit.total:noncovered.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
266. ExplanationOfBenefit.total:noncovered.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
268. ExplanationOfBenefit.total:negotiated | |
Slice Name | negotiated |
Definition | Categorized monetary totals for the adjudication. |
Short | Total negotiated amount - Must include in non-zero total across all AEoBsAdjudication totals |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
270. ExplanationOfBenefit.total:negotiated.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
272. ExplanationOfBenefit.total:negotiated.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
274. ExplanationOfBenefit.total:negotiated.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
276. ExplanationOfBenefit.total:eligible | |
Slice Name | eligible |
Definition | Categorized monetary totals for the adjudication. |
Short | Total 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
278. ExplanationOfBenefit.total:eligible.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
280. ExplanationOfBenefit.total:eligible.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
282. ExplanationOfBenefit.total:eligible.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
284. ExplanationOfBenefit.total:benefit | |
Slice Name | benefit |
Definition | Categorized monetary totals for the adjudication. |
Short | Total 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. |
Control | 0..1* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
286. ExplanationOfBenefit.total:benefit.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
288. ExplanationOfBenefit.total:benefit.category | |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Short | Type of adjudication information |
Comments | For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
Control | 1..1 |
Binding | For example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication (example to http://hl7.org/fhir/ValueSet/adjudication )The adjudication codes. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the type of total provided. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
290. ExplanationOfBenefit.total:benefit.amount | |
Definition | Monetary total amount associated with the category. |
Short | Financial total for the category |
Control | 1..1 |
Type | Money |
Is Modifier | false |
Summary | true |
Requirements | Needed to convey the total monetary amount. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
292. ExplanationOfBenefit.processNote | |
Definition | A note that describes or explains adjudication results in a human readable form. |
Short | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possibleNote concerning adjudication |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Requirements | Provides the insurer specific textual explanations associated with the processing. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
294. ExplanationOfBenefit.processNote.extension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.processNote.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
296. ExplanationOfBenefit.processNote.extension:processNoteClass | |
Slice Name | processNoteClass |
Definition | This extension is used to indicate a the class of AEOB Claim process notes |
Short | ProcessNote Class |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Extension(ProcessNote Class) (Extension Type: CodeableConcept) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
298. ExplanationOfBenefit.processNote.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
300. ExplanationOfBenefit.benefitPeriod | |
Definition | The term of the benefits documented in this response. |
Short | When the benefits are applicable |
Comments | Not applicable when use=claim. |
Control | 10..1 |
Type | Period |
Is Modifier | false |
Summary | false |
Requirements | Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
302. ExplanationOfBenefit.benefitBalance | |
Definition | Balance by Benefit Category. |
Short | Balance by Benefit Category |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
304. ExplanationOfBenefit.benefitBalance.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
306. ExplanationOfBenefit.benefitBalance.category | |
Definition | Code to identify the general type of benefits under which products and services are provided. |
Short | Benefit classification |
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
Control | 1..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to convey the category of service or product for which eligibility is sought. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
308. ExplanationOfBenefit.benefitBalance.unit | |
Definition | Indicates if the benefits apply to an individual or to the family. |
Short | Individual or family |
Control | 10..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed for the understanding of the benefits. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
310. ExplanationOfBenefit.benefitBalance.term | |
Definition | The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'. |
Short | Annual or lifetime |
Control | 10..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed for the understanding of the benefits. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
312. ExplanationOfBenefit.benefitBalance.financial | |
Definition | Benefits Used to date. |
Short | Benefit Summary |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
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. |
Short | ExtensionAdditional content defined by implementations |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ExplanationOfBenefit.benefitBalance.financial.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
316. ExplanationOfBenefit.benefitBalance.financial.extension:remaining | |
Slice Name | remaining |
Definition | The quantity of the benefit remaining to date. |
Short | Benefit Remaining |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Extension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )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). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
320. ExplanationOfBenefit.benefitBalance.financial.type | |
Definition | Classification of benefit being provided. |
Short | Benefit classification |
Comments | For example: deductible, visits, benefit amount. |
Control | 1..1 |
Binding | The 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 ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Needed to convey the nature of the benefit. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
322. ExplanationOfBenefit.benefitBalance.financial.allowed[x] | |
Definition | The quantity of the benefit which is permitted under the coverage. |
Short | Benefits allowed |
Control | 10..1 |
Type | Choice of: unsignedInt, Money, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | Choice of: unsignedInt, Money, string |
Summary | false |
Requirements | Needed to convey the benefits offered under the coverage. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
324. ExplanationOfBenefit.benefitBalance.financial.used[x] | |
Definition | The quantity of the benefit which have been consumed to date. |
Short | Benefits used |
Control | 10..1 |
Type | Choice of: unsignedInt, Money |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | Choice of: unsignedInt, Money |
Summary | false |
Requirements | Needed to convey the benefits consumed to date. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. ExplanationOfBenefit | |||||
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided. | ||||
Short | Explanation of Benefit resource | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | EOB | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() )dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() )pct-aeob-1: Institutional EOB: SHALL have serviceDescription at the item or header level (can be at both locations) ( extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() )pct-aeob-2: Institutional EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists() )pct-aeob-3: Institutional EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) ( adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists() ) | ||||
2. ExplanationOfBenefit.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. ExplanationOfBenefit.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. ExplanationOfBenefit.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. ExplanationOfBenefit.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
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. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
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. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. ExplanationOfBenefit.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 1..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
16. ExplanationOfBenefit.extension:gfeReference | |||||
Slice Name | gfeReference | ||||
Definition | This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB. | ||||
Short | The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. | ||||
Control | 1..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension(GFE Reference) (Extension Type: Reference(PCT GFE Bundle)) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. ExplanationOfBenefit.extension:serviceDescription | |||||
Slice Name | serviceDescription | ||||
Definition | This extension is used to communicate a plain language description of the procedure, product, or service. | ||||
Short | Service Description | ||||
Control | 0..1 This element is affected by the following invariants: ele-1, pct-aeob-1 | ||||
Type | Extension(Service Description) (Extension Type: string) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
20. ExplanationOfBenefit.extension:outOfNetworkProviderInfo | |||||
Slice Name | outOfNetworkProviderInfo | ||||
Definition | This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services. | ||||
Short | In Network Provider Options Link | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(In Network Provider Options Link) (Extension Type: url) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
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). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
24. ExplanationOfBenefit.identifier | |||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short | Business Identifier for the resource | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 1..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
26. ExplanationOfBenefit.identifier:INTER | |||||
Slice Name | INTER | ||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short | Intermediary System Identifier | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. ExplanationOfBenefit.identifier:INTER.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
30. ExplanationOfBenefit.identifier:INTER.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
32. ExplanationOfBenefit.identifier:INTER.use | |||||
Definition | The purpose of this identifier. | ||||
Short | usual | official | temp | secondary | old (If known) | ||||
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||||
Control | 0..1 | ||||
Binding | The 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 . | ||||
Type | code | ||||
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. ExplanationOfBenefit.identifier:INTER.type | |||||
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||||
Short | Description 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. | ||||
Control | 1..1 | ||||
Binding | Unless 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. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. ExplanationOfBenefit.identifier:INTER.system | |||||
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||||
Short | The namespace for the identifier value | ||||
Comments | Identifier.system is always case sensitive. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||||
Example | <br/><b>General</b>:http://www.acme.com/identifiers/patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. ExplanationOfBenefit.identifier:INTER.value | |||||
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||||
Short | The 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Example | <br/><b>General</b>:123456 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. ExplanationOfBenefit.identifier:INTER.period | |||||
Definition | Time period during which identifier is/was valid for use. | ||||
Short | Time period when id is/was valid for use | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. ExplanationOfBenefit.identifier:INTER.assigner | |||||
Definition | Organization that issued/manages the identifier. | ||||
Short | Organization 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. | ||||
Control | 0..1 | ||||
Type | Reference(Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. ExplanationOfBenefit.identifier:uniqueclaimid | |||||
Slice Name | uniqueclaimid | ||||
Definition | A unique identifier assigned to this explanation of benefit. | ||||
Short | Unique Claim ID | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 1..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows EOBs to be distinguished and referenced. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. ExplanationOfBenefit.identifier:uniqueclaimid.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
48. ExplanationOfBenefit.identifier:uniqueclaimid.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.identifier.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
50. ExplanationOfBenefit.identifier:uniqueclaimid.use | |||||
Definition | The purpose of this identifier. | ||||
Short | usual | official | temp | secondary | old (If known) | ||||
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||||
Control | 0..1 | ||||
Binding | The 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 . | ||||
Type | code | ||||
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. ExplanationOfBenefit.identifier:uniqueclaimid.type | |||||
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||||
Short | Description 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. | ||||
Control | 1..1 | ||||
Binding | Unless 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. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. ExplanationOfBenefit.identifier:uniqueclaimid.system | |||||
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||||
Short | The namespace for the identifier value | ||||
Comments | Identifier.system is always case sensitive. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||||
Example | <br/><b>General</b>:http://www.acme.com/identifiers/patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. ExplanationOfBenefit.identifier:uniqueclaimid.value | |||||
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||||
Short | The 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Example | <br/><b>General</b>:123456 | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. ExplanationOfBenefit.identifier:uniqueclaimid.period | |||||
Definition | Time period during which identifier is/was valid for use. | ||||
Short | Time period when id is/was valid for use | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. ExplanationOfBenefit.identifier:uniqueclaimid.assigner | |||||
Definition | Organization that issued/manages the identifier. | ||||
Short | Organization 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. | ||||
Control | 0..1 | ||||
Type | Reference(Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. ExplanationOfBenefit.status | |||||
Definition | The status of the resource instance. | ||||
Short | active | cancelled | draft | entered-in-error | ||||
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from ExplanationOfBenefitStatus (required to http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 )A code specifying the state of the resource instance. | ||||
Type | code | ||||
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. ExplanationOfBenefit.type | |||||
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | ||||
Short | Category or discipline | ||||
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from PCT Advance Explanation of Benefit Type Value Set (required to http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTAEOBTypeVS ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. ExplanationOfBenefit.subType | |||||
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | ||||
Short | More granular claim type | ||||
Comments | This may contain the local bill type codes such as the US UB-04 bill type code. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleClaimSubTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-subtype )A more granular claim typecode. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. ExplanationOfBenefit.use | |||||
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. | ||||
Short | claim | preauthorization | predetermination | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from Use (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 )Complete, proposed, exploratory, other. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | This element is required to understand the nature of the request for adjudication. | ||||
Pattern Value | predetermination | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. ExplanationOfBenefit.patient | |||||
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought. | ||||
Short | The recipient of the products and services | ||||
Control | 1..1 | ||||
Type | Reference(HRex Patient Demographics) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
72. ExplanationOfBenefit.billablePeriod | |||||
Definition | The period for which charges are being submitted. | ||||
Short | Relevant time frame for the claim | ||||
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. ExplanationOfBenefit.created | |||||
Definition | The date this resource was created. | ||||
Short | The 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. | ||||
Control | 1..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Need to record a timestamp for use by both the recipient and the issuer. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. ExplanationOfBenefit.enterer | |||||
Definition | Individual who created the claim, predetermination or preauthorization. | ||||
Short | Author of the claim | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some jurisdictions require the contact information for personnel completing claims. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. ExplanationOfBenefit.insurer | |||||
Definition | The party responsible for authorization, adjudication and reimbursement. | ||||
Short | Party responsible for reimbursement | ||||
Control | 1..1 | ||||
Type | Reference(PCT Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. ExplanationOfBenefit.provider | |||||
Definition | The provider which is responsible for the claim, predetermination or preauthorization. | ||||
Short | Party responsible for the claim | ||||
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. | ||||
Control | 1..1 | ||||
Type | Reference(PCT Practitioner, PCT Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. ExplanationOfBenefit.priority | |||||
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | ||||
Short | Desired processing urgency | ||||
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to http://hl7.org/fhir/ValueSet/process-priority ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. ExplanationOfBenefit.fundsReserveRequested | |||||
Definition | A code to indicate whether and for whom funds are to be reserved for future claims. | ||||
Short | For whom to reserve funds | ||||
Comments | This field is only used for preauthorizations. | ||||
Control | 0..1 | ||||
Binding | For example codes, see Funds Reservation Codes (example to http://hl7.org/fhir/ValueSet/fundsreserve )For whom funds are to be reserved: (Patient, Provider, None). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested. | ||||
Alternate Names | Fund pre-allocation | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. ExplanationOfBenefit.fundsReserve | |||||
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. | ||||
Short | Funds reserved status | ||||
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. | ||||
Control | 0..1 | ||||
Binding | For example codes, see Funds Reservation Codes (example to http://hl7.org/fhir/ValueSet/fundsreserve )For whom funds are to be reserved: (Patient, Provider, None). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. ExplanationOfBenefit.related | |||||
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | ||||
Short | Prior or corollary claims | ||||
Comments | For example, for the original treatment and follow-up exams. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. ExplanationOfBenefit.related.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
92. ExplanationOfBenefit.related.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
94. ExplanationOfBenefit.related.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
96. ExplanationOfBenefit.related.claim | |||||
Definition | Reference to a related claim. | ||||
Short | Reference to the related claim | ||||
Control | 0..1 | ||||
Type | Reference(Claim) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. ExplanationOfBenefit.related.relationship | |||||
Definition | A code to convey how the claims are related. | ||||
Short | How the reference claim is related | ||||
Comments | For example, prior claim or umbrella. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ExampleRelatedClaimRelationshipCodes (example to http://hl7.org/fhir/ValueSet/related-claim-relationship )Relationship of this claim to a related Claim. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some insurers need a declaration of the type of relationship. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. ExplanationOfBenefit.related.reference | |||||
Definition | An alternate organizational reference to the case or file to which this particular claim pertains. | ||||
Short | File or case reference | ||||
Comments | For example, Property/Casualty insurer claim number or Workers Compensation case number. | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
102. ExplanationOfBenefit.prescription | |||||
Definition | Prescription to support the dispensing of pharmacy, device or vision products. | ||||
Short | Prescription authorizing services or products | ||||
Control | 0..1 | ||||
Type | Reference(MedicationRequest, VisionPrescription) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Required to authorize the dispensing of controlled substances and devices. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
104. ExplanationOfBenefit.originalPrescription | |||||
Definition | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | ||||
Short | Original prescription if superceded by fulfiller | ||||
Comments | For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'. | ||||
Control | 0..1 | ||||
Type | Reference(MedicationRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
106. ExplanationOfBenefit.payee | |||||
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy. | ||||
Short | Recipient of benefits payable | ||||
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead. | ||||
Control | 0..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
108. ExplanationOfBenefit.payee.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
110. ExplanationOfBenefit.payee.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
112. ExplanationOfBenefit.payee.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
114. ExplanationOfBenefit.payee.type | |||||
Definition | Type of Party to be reimbursed: Subscriber, provider, other. | ||||
Short | Category of recipient | ||||
Control | 0..1 | ||||
Binding | For example codes, see Claim Payee Type Codes (example to http://hl7.org/fhir/ValueSet/payeetype )A code for the party to be reimbursed. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
116. ExplanationOfBenefit.payee.party | |||||
Definition | Reference to the individual or organization to whom any payment will be made. | ||||
Short | Recipient reference | ||||
Comments | Not required if the payee is 'subscriber' or 'provider'. | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
118. ExplanationOfBenefit.referral | |||||
Definition | A reference to a referral resource. | ||||
Short | Treatment Referral | ||||
Comments | The referral resource which lists the date, practitioner, reason and other supporting information. | ||||
Control | 0..1 | ||||
Type | Reference(ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
120. ExplanationOfBenefit.facility | |||||
Definition | Facility where the services were provided. | ||||
Short | Servicing Facility | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Insurance adjudication can be dependant on where services were delivered. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
122. ExplanationOfBenefit.claim | |||||
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization. | ||||
Short | Claim reference | ||||
Control | 1..1 | ||||
Type | Reference(Claim) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | To provide a link to the original adjudication request. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
124. ExplanationOfBenefit.claim.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
126. ExplanationOfBenefit.claim.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.claim.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
128. ExplanationOfBenefit.claim.reference | |||||
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. | ||||
Short | Literal 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. | ||||
Control | 0..1 This element is affected by the following invariants: ref-1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
130. ExplanationOfBenefit.claim.type | |||||
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). | ||||
Short | Type 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. | ||||
Control | 0..1 | ||||
Binding | Unless 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). | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
132. ExplanationOfBenefit.claim.identifier | |||||
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values). | ||||
Short | GFE 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). | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 1..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
134. ExplanationOfBenefit.claim.identifier.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
136. ExplanationOfBenefit.claim.identifier.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on ExplanationOfBenefit.claim.identifier.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
138. ExplanationOfBenefit.claim.identifier.use | |||||
Definition | The purpose of this identifier. | ||||
Short | usual | official | temp | secondary | old (If known) | ||||
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||||
Control | 0..1 | ||||
Binding | The 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 . | ||||
Type | code | ||||
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
140. ExplanationOfBenefit.claim.identifier.type | |||||
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||||
Short | Description 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. | ||||
Control | 0..1 | ||||
Binding | Unless 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. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
142. ExplanationOfBenefit.claim.identifier.system | |||||
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||||
Short | The namespace for the identifier value | ||||
Comments | Identifier.system is always case sensitive. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||||
Example | <br/><b>General</b>:http://www.acme.com/identifiers/patient | ||||
Invar |