Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

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 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

## Resource Profile: PCTAdvancedEOB - Detailed Descriptions

Page standards status: Trial-use | Maturity Level: 2

Definitions for the davinci-pct-aeob resource profile.

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

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

0. ExplanationOfBenefit
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
Short | Explanation of Benefit resource
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | EOB
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) pct-aeob-1: Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (`extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`) pct-aeob-2: Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`) pct-aeob-3: Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`)
2. ExplanationOfBenefit.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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: value @ url
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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. ExplanationOfBenefit.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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
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: value @ type
16. 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()))
18. 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 http://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: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 Codes http://hl7.org/fhir/ValueSet/identifier-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) 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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "UCID" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ExplanationOfBenefit.status
Definition | The status of the resource instance.
Short | active | cancelled | draft | entered-in-error
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
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()))
24. 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 ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type|4.0.1 (required to `http://hl7.org/fhir/ValueSet/claim-type` )
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()))
26. ExplanationOfBenefit.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Complete, proposed, exploratory, other.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
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()))
28. ExplanationOfBenefit.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile, 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()))
30. 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()))
32. 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()))
34. 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()))
36. ExplanationOfBenefit.priority
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
Short | Desired processing urgency
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
Control | 0..1
Binding | The codes SHALL be taken from For example codes, see ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority|4.0.1 (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Type | CodeableConcept
Is Modifier | false
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()))
38. 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()))
40. ExplanationOfBenefit.claim.identifier
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values). An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
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()))
42. 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 http://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()))
44. 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 | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. ExplanationOfBenefit.claim.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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 | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ExplanationOfBenefit.outcome
Definition | The outcome of the claim, predetermination, or preauthorization processing.
Short | queued | complete | error | partial
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. 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()))
52. ExplanationOfBenefit.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
54. ExplanationOfBenefit.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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()))
56. ExplanationOfBenefit.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
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()))
58. ExplanationOfBenefit.item
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
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()))
60. ExplanationOfBenefit.item.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
62. 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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. ExplanationOfBenefit.item.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())
66. 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()))
68. 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 Set http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1 (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()))
70. ExplanationOfBenefit.item.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
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 Set http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 (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()))
72. ExplanationOfBenefit.item.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
74. ExplanationOfBenefit.item.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
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 Set http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 (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()))
76. ExplanationOfBenefit.item.modifier.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
78. ExplanationOfBenefit.item.serviced[x]
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication The date or dates when the service or product was supplied, performed or completed.
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()))
80. 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()))
82. ExplanationOfBenefit.item.adjudication
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
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: value @ category
84. ExplanationOfBenefit.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
86. ExplanationOfBenefit.item.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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()))
88. 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()))
90. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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: value @ url
92. 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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. ExplanationOfBenefit.item.adjudication:medicalmanagement.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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.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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. ExplanationOfBenefit.item.adjudication:medicalmanagement.amount
Definition | Monetary amount associated with the category.
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()))
100. 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()))
102. 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()))
104. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
106. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Status http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
110. 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()))
112. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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.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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Reason http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
118. 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()))
120. ExplanationOfBenefit.item.adjudication:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
122. ExplanationOfBenefit.item.adjudication: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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. 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()))
126. ExplanationOfBenefit.item.adjudication:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
128. ExplanationOfBenefit.item.adjudication:memberliability.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. 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()))
132. ExplanationOfBenefit.item.adjudication:eligible.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
134. ExplanationOfBenefit.item.adjudication: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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. 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()))
138. ExplanationOfBenefit.item.adjudication:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
140. ExplanationOfBenefit.item.adjudication:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. ExplanationOfBenefit.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
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: value @ category
144. ExplanationOfBenefit.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
146. ExplanationOfBenefit.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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()))
148. 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()))
150. ExplanationOfBenefit.adjudication:medicalmanagement.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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: value @ url
152. 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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
154. ExplanationOfBenefit.adjudication:medicalmanagement.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
156. ExplanationOfBenefit.adjudication:medicalmanagement.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. ExplanationOfBenefit.adjudication:medicalmanagement.amount
Definition | Monetary amount associated with the category.
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()))
160. 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()))
162. 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()))
164. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
166. ExplanationOfBenefit.adjudication:billingnetworkstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "billingnetworkstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
168. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Status http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
170. 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()))
172. ExplanationOfBenefit.adjudication:renderingnetworkstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
174. ExplanationOfBenefit.adjudication:renderingnetworkstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "renderingnetworkstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Status http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
178. 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()))
180. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
182. ExplanationOfBenefit.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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Status http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
186. 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()))
188. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
190. ExplanationOfBenefit.adjudication:adjustmentreason.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
192. ExplanationOfBenefit.adjudication:adjustmentreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 Reason http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1 (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()))
194. 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()))
196. ExplanationOfBenefit.adjudication:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
198. ExplanationOfBenefit.adjudication:submitted.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
200. 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()))
202. ExplanationOfBenefit.adjudication:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
204. ExplanationOfBenefit.adjudication:memberliability.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
206. 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()))
208. ExplanationOfBenefit.adjudication:eligible.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
210. ExplanationOfBenefit.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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT GFE Item Adjudication Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
212. 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()))
214. ExplanationOfBenefit.adjudication:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
216. ExplanationOfBenefit.adjudication:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
218. ExplanationOfBenefit.total
Definition | Categorized monetary totals for the adjudication.
Short | Adjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 30..*
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: value @ category
220. ExplanationOfBenefit.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
222. ExplanationOfBenefit.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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()))
224. 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()))
226. 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()))
228. ExplanationOfBenefit.total:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
230. ExplanationOfBenefit.total:submitted.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
232. ExplanationOfBenefit.total:submitted.amount
Definition | Monetary total amount associated with the category.
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()))
234. ExplanationOfBenefit.total:memberliability
Slice Name | memberliability
Definition | Categorized monetary totals for the adjudication.
Short | Total member liabilityAdjudication 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()))
236. ExplanationOfBenefit.total:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
238. ExplanationOfBenefit.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 | Unless not suitable, these codes SHALL be taken from For example codes, see PCT Total Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
240. ExplanationOfBenefit.total:memberliability.amount
Definition | Monetary total amount associated with the category.
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()))
242. ExplanationOfBenefit.total:eligible
Slice Name | eligible
Definition | Categorized monetary totals for the adjudication.
Short | Total eligible amountAdjudication 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 | 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()))
244. ExplanationOfBenefit.total:eligible.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
246. ExplanationOfBenefit.total:eligible.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
248. ExplanationOfBenefit.total:eligible.amount
Definition | Monetary total amount associated with the category.
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()))
250. ExplanationOfBenefit.total:innetwork
Slice Name | innetwork
Definition | Categorized monetary totals for the adjudication.
Short | Total in network amount - only include when total type is applicableAdjudication 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()))
252. ExplanationOfBenefit.total:innetwork.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
254. ExplanationOfBenefit.total:innetwork.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "innetwork" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
256. ExplanationOfBenefit.total:innetwork.amount
Definition | Monetary total amount associated with the category.
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()))
258. ExplanationOfBenefit.total:outofnetwork
Slice Name | outofnetwork
Definition | Categorized monetary totals for the adjudication.
Short | Total out of network amount - only include when total type is applicableAdjudication 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()))
260. ExplanationOfBenefit.total:outofnetwork.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
262. ExplanationOfBenefit.total:outofnetwork.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "outofnetwork" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
264. ExplanationOfBenefit.total:outofnetwork.amount
Definition | Monetary total amount associated with the category.
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()))
266. ExplanationOfBenefit.total:noncovered
Slice Name | noncovered
Definition | Categorized monetary totals for the adjudication.
Short | Total noncovered amount - only include when total type is applicableAdjudication 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()))
268. ExplanationOfBenefit.total:noncovered.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
270. ExplanationOfBenefit.total:noncovered.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication", "code" : "noncovered" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
272. ExplanationOfBenefit.total:noncovered.amount
Definition | Monetary total amount associated with the category.
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()))
274. ExplanationOfBenefit.total:negotiated
Slice Name | negotiated
Definition | Categorized monetary totals for the adjudication.
Short | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contractAdjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
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()))
276. ExplanationOfBenefit.total:negotiated.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
278. ExplanationOfBenefit.total:negotiated.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "negotiated" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
280. ExplanationOfBenefit.total:negotiated.amount
Definition | Monetary total amount associated with the category.
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()))
282. ExplanationOfBenefit.total:benefit
Slice Name | benefit
Definition | Categorized monetary totals for the adjudication.
Short | Total benefit amount - only include when total type is applicableAdjudication 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()))
284. ExplanationOfBenefit.total:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
286. ExplanationOfBenefit.total:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
288. ExplanationOfBenefit.total:benefit.amount
Definition | Monetary total amount associated with the category.
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()))
290. 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 possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.Note concerning adjudication
Comments | These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
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()))
292. ExplanationOfBenefit.processNote.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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: value @ url
294. 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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
296. ExplanationOfBenefit.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
298. 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()))
300. ExplanationOfBenefit.benefitBalance
Definition | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates. Balance by Benefit Category.
Short | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.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()))
302. ExplanationOfBenefit.benefitBalance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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())
304. 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 codes http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1 (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()))
306. ExplanationOfBenefit.benefitBalance.category.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
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 UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit|4.0.1 (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 BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term|4.0.1 (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: value @ url
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
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
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 Set http://hl7.org/fhir/ValueSet/benefit-type|4.0.1 (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 foundhere

0. ExplanationOfBenefit
Invariants | pct-aeob-1: Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (`extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`) pct-aeob-2: Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`) pct-aeob-3: Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`)
2. ExplanationOfBenefit.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: value @ url
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: value @ type
12. 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
14. ExplanationOfBenefit.identifier:uniqueclaimid.type
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "UCID" }] }`
16. ExplanationOfBenefit.type
Binding | The codes SHALL be taken from ClaimTypeCodes (required to `http://hl7.org/fhir/ValueSet/claim-type` )
18. ExplanationOfBenefit.use
Pattern Value | `predetermination`
20. ExplanationOfBenefit.patient
Type | Reference(US Core Patient Profile)
22. 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.
24. ExplanationOfBenefit.insurer
Type | Reference(PCT Organization)
26. ExplanationOfBenefit.provider
Type | Reference(PCT Practitioner, PCT Organization)
28. ExplanationOfBenefit.priority
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Must Support | true
30. ExplanationOfBenefit.claim
Control | 1..?
32. ExplanationOfBenefit.claim.identifier
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).
Short | GFE identifier of the originally submitted claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
34. ExplanationOfBenefit.claim.identifier.system
Must Support | true
36. ExplanationOfBenefit.claim.identifier.value
Control | 1..?
38. ExplanationOfBenefit.insurance
40. ExplanationOfBenefit.insurance.coverage
Type | Reference(PCT Coverage)
42. ExplanationOfBenefit.item
Control | 1..?
44. ExplanationOfBenefit.item.extension
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
46. 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
48. 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` )
50. 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` )
52. ExplanationOfBenefit.item.productOrService.coding
Invariants | pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
54. 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
56. ExplanationOfBenefit.item.modifier.coding
Invariants | pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
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: value @ category
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: value @ url
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
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: value @ category
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: value @ url
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "billingnetworkstatus" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "renderingnetworkstatus" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
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 | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
162. ExplanationOfBenefit.total
Control | 3..?
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.total`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ category
164. ExplanationOfBenefit.total.category
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
170. ExplanationOfBenefit.total:memberliability
Slice Name | memberliability
Short | Total member liability
Control | 1..1
Must Support | true
172. ExplanationOfBenefit.total:memberliability.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
174. ExplanationOfBenefit.total:eligible
Slice Name | eligible
Short | Total 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 | 1..1
Must Support | true
176. ExplanationOfBenefit.total:eligible.category
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
178. ExplanationOfBenefit.total:innetwork
Slice Name | innetwork
Short | Total in network amount - only include when total type is applicable
Control | 0..1
Must Support | true
180. ExplanationOfBenefit.total:innetwork.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "innetwork" }] }`
182. ExplanationOfBenefit.total:outofnetwork
Slice Name | outofnetwork
Short | Total out of network amount - only include when total type is applicable
Control | 0..1
Must Support | true
184. ExplanationOfBenefit.total:outofnetwork.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "outofnetwork" }] }`
186. ExplanationOfBenefit.total:noncovered
Slice Name | noncovered
Short | Total noncovered amount - only include when total type is applicable
Control | 0..1
Must Support | true
188. ExplanationOfBenefit.total:noncovered.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication", "code" : "noncovered" }] }`
190. ExplanationOfBenefit.total:negotiated
Slice Name | negotiated
Short | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
Control | 0..1
Must Support | true
192. ExplanationOfBenefit.total:negotiated.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "negotiated" }] }`
194. ExplanationOfBenefit.total:benefit
Slice Name | benefit
Short | Total benefit amount - only include when total type is applicable
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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
198. ExplanationOfBenefit.processNote
Short | Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
Comments | These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
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: value @ url
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
Definition | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.
Short | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
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.category.text
Control | 1..?
Must Support | true
212. ExplanationOfBenefit.benefitBalance.unit
Control | 1..?
Binding | The codes SHALL be taken from UnitTypeCodes (required to `http://hl7.org/fhir/ValueSet/benefit-unit` )
214. ExplanationOfBenefit.benefitBalance.term
Control | 1..?
Binding | The codes SHALL be taken from BenefitTermCodes (required to `http://hl7.org/fhir/ValueSet/benefit-term` )
216. ExplanationOfBenefit.benefitBalance.financial
Control | 1..?
218. 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: value @ url
220. ExplanationOfBenefit.benefitBalance.financial.extension:remaining
Slice Name | remaining
Control | 0..1
Type | Extension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money)
Must Support | true
222. 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` )
224. 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
226. 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 foundhere

0. ExplanationOfBenefit
Definition | This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
Short | Explanation of Benefit resource
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | EOB
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (`contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (`contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`) pct-aeob-1: Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations) (`extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()`) pct-aeob-2: Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()`) pct-aeob-3: Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations) (`adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()`)
2. ExplanationOfBenefit.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
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|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
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: value @ url
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
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()`)
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
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()`)
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
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()`)
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: value @ type
26. 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())`)
28. ExplanationOfBenefit.identifier:uniqueclaimid.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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: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: value @ url
32. 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())`)
34. ExplanationOfBenefit.identifier:uniqueclaimid.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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|4.0.1` ) 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 | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "UCID" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. ExplanationOfBenefit.identifier:uniqueclaimid.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
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 | General: 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: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 | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. ExplanationOfBenefit.identifier:uniqueclaimid.period
Definition | Time period during which identifier is/was valid for use.
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: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())`)
44. 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())`)
46. 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 ClaimTypeCodes (required to `http://hl7.org/fhir/ValueSet/claim-type` )
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())`)
48. ExplanationOfBenefit.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Control | 0..1
Binding | For example codes, see ExampleClaimSubTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` ) A more granular claim typecode.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. ExplanationOfBenefit.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
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())`)
52. ExplanationOfBenefit.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile)
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())`)
54. 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())`)
56. 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())`)
58. 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())`)
60. 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())`)
62. 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())`)
64. 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())`)
66. ExplanationOfBenefit.fundsReserveRequested
Definition | A code to indicate whether and for whom funds are to be reserved for future claims.
Short | For whom to reserve funds
Comments | This field is only used for preauthorizations.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.
Alternate Names | Fund pre-allocation
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
68. ExplanationOfBenefit.fundsReserve
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Short | Funds reserved status
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
70. ExplanationOfBenefit.related
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
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())`)
72. ExplanationOfBenefit.related.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
74. ExplanationOfBenefit.related.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
76. ExplanationOfBenefit.related.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
78. 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())`)
80. ExplanationOfBenefit.related.relationship
Definition | A code to convey how the claims are related.
Short | How the reference claim is related
Comments | For example, prior claim or umbrella.
Control | 0..1
Binding | For example codes, see ExampleRelatedClaimRelationshipCodes (example to `http://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1` ) Relationship of this claim to a related Claim.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some insurers need a declaration of the type of relationship.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
82. 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())`)
84. 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())`)
86. 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())`)
88. 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())`)
90. ExplanationOfBenefit.payee.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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.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()`)
94. ExplanationOfBenefit.payee.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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.payee.type
Definition | Type of Party to be reimbursed: Subscriber, provider, other.
Short | Category of recipient
Control | 0..1
Binding | For example codes, see Claim Payee Type Codes (example to `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. 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())`)
100. 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())`)
102. 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())`)
104. 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())`)
106. ExplanationOfBenefit.claim.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
108. ExplanationOfBenefit.claim.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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: value @ url
110. ExplanationOfBenefit.claim.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
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())`)
112. ExplanationOfBenefit.claim.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
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|4.0.1` ) 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())`)
114. ExplanationOfBenefit.claim.identifier
Definition | Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).
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())`)
116. ExplanationOfBenefit.claim.identifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
118. ExplanationOfBenefit.claim.identifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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: value @ url
120. 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())`)
122. ExplanationOfBenefit.claim.identifier.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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|4.0.1` ) 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())`)
124. 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 | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. ExplanationOfBenefit.claim.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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 | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. ExplanationOfBenefit.claim.identifier.period
Definition | Time period during which identifier is/was valid for use.
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())`)
130. ExplanationOfBenefit.claim.identifier.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())`)
132. ExplanationOfBenefit.claim.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
134. ExplanationOfBenefit.claimResponse
Definition | The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.
Short | Claim response reference
Control | 0..1
Type | Reference(ClaimResponse)
Is Modifier | false
Summary | false
Requirements | To provide a link to the original adjudication response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
136. ExplanationOfBenefit.outcome
Definition | The outcome of the claim, predetermination, or preauthorization processing.
Short | queued | complete | error | partial
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
138. ExplanationOfBenefit.disposition
Definition | A human readable description of the status of the adjudication.
Short | Disposition Message
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provided for user display.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
140. ExplanationOfBenefit.preAuthRef
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication.
Short | Preauthorization reference
Comments | This value is only present on preauthorization adjudications.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
142. ExplanationOfBenefit.preAuthRefPeriod
Definition | The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.
Short | Preauthorization in-effect period
Comments | This value is only present on preauthorization adjudications.
Control | 0..*
Type | Period
Is Modifier | false
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
144. ExplanationOfBenefit.careTeam
Definition | The members of the team who provided the products and services.
Short | Care Team members
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
146. ExplanationOfBenefit.careTeam.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
148. ExplanationOfBenefit.careTeam.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
150. ExplanationOfBenefit.careTeam.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
152. ExplanationOfBenefit.careTeam.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
154. ExplanationOfBenefit.careTeam.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
156. ExplanationOfBenefit.careTeam.responsible
Definition | The party who is billing and/or responsible for the claimed products or services.
Short | Indicator of the lead practitioner
Comments | Responsible might not be required when there is only a single provider listed.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
158. ExplanationOfBenefit.careTeam.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 0..1
Binding | For example codes, see ClaimCareTeamRoleCodes (example to `http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1` ) The role codes for the care team members.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
160. ExplanationOfBenefit.careTeam.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization
Control | 0..1
Binding | For example codes, see ExampleProviderQualificationCodes (example to `http://hl7.org/fhir/ValueSet/provider-qualification|4.0.1` ) Provider professional qualifications.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. ExplanationOfBenefit.supportingInfo
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Supporting information
Comments | Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
164. ExplanationOfBenefit.supportingInfo.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
166. ExplanationOfBenefit.supportingInfo.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
168. ExplanationOfBenefit.supportingInfo.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
170. ExplanationOfBenefit.supportingInfo.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
172. ExplanationOfBenefit.supportingInfo.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | For example codes, see ClaimInformationCategoryCodes (example to `http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1` ) The valuset used for additional information category codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
174. ExplanationOfBenefit.supportingInfo.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Short | Type of information
Comments | This may contain the local bill type codes such as the US UB-04 bill type code.
Control | 0..1
Binding | For example codes, see ExceptionCodes (example to `http://hl7.org/fhir/ValueSet/claim-exception|4.0.1` ) The valuset used for additional information codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
176. ExplanationOfBenefit.supportingInfo.timing[x]
Definition | The date when or period to which this information refers.
Short | When it occurred
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
178. ExplanationOfBenefit.supportingInfo.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 0..1
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
180. ExplanationOfBenefit.supportingInfo.reason
Definition | Provides the reason in the situation where a reason code is required in addition to the content.
Short | Explanation for the information
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes (example to `http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1` ) Reason codes for the missing teeth.
Type | Coding
Is Modifier | false
Summary | false
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
182. ExplanationOfBenefit.diagnosis
Definition | Information about diagnoses relevant to the claim items.
Short | Pertinent diagnosis information
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
184. ExplanationOfBenefit.diagnosis.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
186. ExplanationOfBenefit.diagnosis.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
188. ExplanationOfBenefit.diagnosis.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
190. ExplanationOfBenefit.diagnosis.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
192. ExplanationOfBenefit.diagnosis.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | For example codes, see ICD-10Codes (example to `http://hl7.org/fhir/ValueSet/icd-10|4.0.1` ) ICD10 Diagnostic codes.
Type | Choice of: CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
194. ExplanationOfBenefit.diagnosis.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 0..*
Binding | For example codes, see ExampleDiagnosisTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1` ) The type of the diagnosis: admitting, principal, discharge.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
196. ExplanationOfBenefit.diagnosis.onAdmission
Definition | Indication of whether the diagnosis was present on admission to a facility.
Short | Present on admission
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1` ) Present on admission.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
198. ExplanationOfBenefit.diagnosis.packageCode
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
Short | Package billing code
Comments | For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1` ) The DRG codes associated with the diagnosis.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
200. ExplanationOfBenefit.procedure
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
202. ExplanationOfBenefit.procedure.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
204. ExplanationOfBenefit.procedure.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
206. ExplanationOfBenefit.procedure.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
208. ExplanationOfBenefit.procedure.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
210. ExplanationOfBenefit.procedure.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Control | 0..*
Binding | For example codes, see ExampleProcedureTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1` ) Example procedure type codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
212. ExplanationOfBenefit.procedure.date
Definition | Date and optionally time the procedure was performed.
Short | When the procedure was performed
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for auditing purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
214. ExplanationOfBenefit.procedure.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | For example codes, see ICD-10ProcedureCodes (example to `http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1` ) ICD10 Procedure codes.
Type | Choice of: CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
216. ExplanationOfBenefit.procedure.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
218. ExplanationOfBenefit.precedence
Definition | This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.
Short | Precedence (primary, secondary, etc.)
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to coordinate between multiple EOBs for the same suite of services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
220. 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())`)
222. ExplanationOfBenefit.insurance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
224. ExplanationOfBenefit.insurance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
226. ExplanationOfBenefit.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
228. ExplanationOfBenefit.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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())`)
230. ExplanationOfBenefit.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Short | Insurance information
Control | 1..1
Type | Reference(PCT 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())`)
232. ExplanationOfBenefit.insurance.preAuthRef
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
Short | Prior authorization reference number
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
234. ExplanationOfBenefit.accident
Definition | Details of a accident which resulted in injuries which required the products and services listed in the claim.
Short | Details of the event
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
236. ExplanationOfBenefit.accident.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
238. ExplanationOfBenefit.accident.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
240. ExplanationOfBenefit.accident.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
242. ExplanationOfBenefit.accident.date
Definition | Date of an accident event related to the products and services contained in the claim.
Short | When the incident occurred
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for audit purposes and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
244. ExplanationOfBenefit.accident.type
Definition | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Short | The nature of the accident
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ActIncidentCode (3.0.0) (extensible to `http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0` ) Type of accident: work place, auto, etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Coverage may be dependant on the type of accident.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
246. ExplanationOfBenefit.accident.location[x]
Definition | The physical location of the accident event.
Short | Where the event occurred
Control | 0..1
Type | Choice of: Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Required for audit purposes and determination of applicable insurance liability.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
248. ExplanationOfBenefit.item
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Short | Product or service provided
Control | 1..*
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())`)
250. ExplanationOfBenefit.item.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
252. ExplanationOfBenefit.item.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
254. 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
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()`)
256. ExplanationOfBenefit.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
258. 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())`)
260. ExplanationOfBenefit.item.careTeamSequence
Definition | Care team members related to this service or product.
Short | Applicable care team members
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to identify the individuals and their roles in the provision of the product or service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
262. ExplanationOfBenefit.item.diagnosisSequence
Definition | Diagnoses applicable for this service or product.
Short | Applicable diagnoses
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to related the product or service to the associated diagnoses.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
264. ExplanationOfBenefit.item.procedureSequence
Definition | Procedures applicable for this service or product.
Short | Applicable procedures
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to provide any listed specific procedures to support the product or service being claimed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
266. ExplanationOfBenefit.item.informationSequence
Definition | Exceptions, special conditions and supporting information applicable for this service or product.
Short | Applicable exception and supporting information
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to reference the supporting information items that relate directly to this product or service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
268. 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 PCT GFE NUBC Revenue Value Set (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())`)
270. ExplanationOfBenefit.item.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
272. ExplanationOfBenefit.item.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
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 Claim Medical Product or Service Value Set (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())`)
274. ExplanationOfBenefit.item.productOrService.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
276. ExplanationOfBenefit.item.productOrService.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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.item.productOrService.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
278. ExplanationOfBenefit.item.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
280. ExplanationOfBenefit.item.productOrService.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
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
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
282. ExplanationOfBenefit.item.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
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 PCT GFE Item CPT - HCPCS Value Set (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())`)
284. ExplanationOfBenefit.item.modifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
286. ExplanationOfBenefit.item.modifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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.item.modifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
288. ExplanationOfBenefit.item.modifier.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
290. ExplanationOfBenefit.item.modifier.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
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
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
292. ExplanationOfBenefit.item.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
294. ExplanationOfBenefit.item.serviced[x]
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication
Short | This is the planned or estimated date(s)s of service
Control | 1..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())`)
296. ExplanationOfBenefit.item.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place|4.0.1` ) Place where the service is rendered.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
298. 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())`)
300. ExplanationOfBenefit.item.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
302. ExplanationOfBenefit.item.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
304. ExplanationOfBenefit.item.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
306. ExplanationOfBenefit.item.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
308. ExplanationOfBenefit.item.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical location
Comments | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
310. ExplanationOfBenefit.item.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
312. ExplanationOfBenefit.item.encounter
Definition | A billed item may include goods or services provided in multiple encounters.
Short | Encounters related to this billed item
Control | 0..*
Type | Reference(Encounter)
Is Modifier | false
Summary | false
Requirements | Used in some jurisdictions to link clinical events to claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
314. ExplanationOfBenefit.item.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
316. ExplanationOfBenefit.item.adjudication
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Short | Adjudication details
Control | 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())`)
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: value @ category
318. ExplanationOfBenefit.item.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
320. ExplanationOfBenefit.item.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
322. ExplanationOfBenefit.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
324. ExplanationOfBenefit.item.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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())`)
326. ExplanationOfBenefit.item.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
328. ExplanationOfBenefit.item.adjudication.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
330. ExplanationOfBenefit.item.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
332. 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())`)
334. ExplanationOfBenefit.item.adjudication:medicalmanagement.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
336. ExplanationOfBenefit.item.adjudication:medicalmanagement.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.item.adjudication.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
338. ExplanationOfBenefit.item.adjudication:medicalmanagement.extension:subjectToMedicalMgmt
Slice 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
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()`)
340. ExplanationOfBenefit.item.adjudication:medicalmanagement.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
342. ExplanationOfBenefit.item.adjudication:medicalmanagement.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
344. ExplanationOfBenefit.item.adjudication:medicalmanagement.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
346. 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..0
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())`)
348. 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..0
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())`)
350. 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.
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())`)
352. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
354. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
356. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
358. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
360. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Payer Benefit Payment Status (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())`)
362. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
364. ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
366. 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 Reason
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())`)
368. ExplanationOfBenefit.item.adjudication:adjustmentreason.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
370. ExplanationOfBenefit.item.adjudication:adjustmentreason.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
372. ExplanationOfBenefit.item.adjudication:adjustmentreason.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
374. ExplanationOfBenefit.item.adjudication:adjustmentreason.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
376. ExplanationOfBenefit.item.adjudication:adjustmentreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Adjustment 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())`)
378. ExplanationOfBenefit.item.adjudication:adjustmentreason.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
380. ExplanationOfBenefit.item.adjudication:adjustmentreason.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
382. 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 amount
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())`)
384. ExplanationOfBenefit.item.adjudication:submitted.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
386. ExplanationOfBenefit.item.adjudication:submitted.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
388. ExplanationOfBenefit.item.adjudication:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
390. ExplanationOfBenefit.item.adjudication:submitted.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
392. ExplanationOfBenefit.item.adjudication:submitted.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
394. ExplanationOfBenefit.item.adjudication:submitted.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
396. ExplanationOfBenefit.item.adjudication:submitted.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
398. 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 liability
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())`)
400. ExplanationOfBenefit.item.adjudication:memberliability.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
402. ExplanationOfBenefit.item.adjudication:memberliability.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
404. ExplanationOfBenefit.item.adjudication:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
406. ExplanationOfBenefit.item.adjudication:memberliability.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
408. ExplanationOfBenefit.item.adjudication:memberliability.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
410. ExplanationOfBenefit.item.adjudication:memberliability.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
412. ExplanationOfBenefit.item.adjudication:memberliability.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
414. 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 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
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())`)
416. ExplanationOfBenefit.item.adjudication:eligible.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
418. ExplanationOfBenefit.item.adjudication:eligible.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
420. ExplanationOfBenefit.item.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()`)
422. ExplanationOfBenefit.item.adjudication:eligible.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
424. ExplanationOfBenefit.item.adjudication:eligible.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
426. ExplanationOfBenefit.item.adjudication:eligible.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
428. ExplanationOfBenefit.item.adjudication:eligible.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
430. 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 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
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())`)
432. ExplanationOfBenefit.item.adjudication:benefit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
434. ExplanationOfBenefit.item.adjudication:benefit.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
436. ExplanationOfBenefit.item.adjudication:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
438. ExplanationOfBenefit.item.adjudication:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
440. ExplanationOfBenefit.item.adjudication:benefit.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
442. ExplanationOfBenefit.item.adjudication:benefit.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
444. ExplanationOfBenefit.item.adjudication:benefit.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
446. ExplanationOfBenefit.item.detail
Definition | Second-tier of goods and services.
Short | Additional items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
448. ExplanationOfBenefit.item.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
450. ExplanationOfBenefit.item.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
452. ExplanationOfBenefit.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
454. ExplanationOfBenefit.item.detail.sequence
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Product or service provided
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
456. ExplanationOfBenefit.item.detail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
458. ExplanationOfBenefit.item.detail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
460. ExplanationOfBenefit.item.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
462. ExplanationOfBenefit.item.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
464. ExplanationOfBenefit.item.detail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
466. ExplanationOfBenefit.item.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
468. ExplanationOfBenefit.item.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
470. ExplanationOfBenefit.item.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
472. ExplanationOfBenefit.item.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
474. ExplanationOfBenefit.item.detail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
476. ExplanationOfBenefit.item.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
478. ExplanationOfBenefit.item.detail.adjudication
Definition | The adjudication results.
Short | Detail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
480. ExplanationOfBenefit.item.detail.subDetail
Definition | Third-tier of goods and services.
Short | Additional items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
482. ExplanationOfBenefit.item.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
484. ExplanationOfBenefit.item.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
486. ExplanationOfBenefit.item.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
488. ExplanationOfBenefit.item.detail.subDetail.sequence
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Product or service provided
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
490. ExplanationOfBenefit.item.detail.subDetail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
492. ExplanationOfBenefit.item.detail.subDetail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral, medical, vision, oral-basic etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
494. ExplanationOfBenefit.item.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
496. ExplanationOfBenefit.item.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
498. ExplanationOfBenefit.item.detail.subDetail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
500. ExplanationOfBenefit.item.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
502. ExplanationOfBenefit.item.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
504. ExplanationOfBenefit.item.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
506. ExplanationOfBenefit.item.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
508. ExplanationOfBenefit.item.detail.subDetail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
510. ExplanationOfBenefit.item.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
512. ExplanationOfBenefit.item.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Subdetail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
514. ExplanationOfBenefit.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
516. ExplanationOfBenefit.addItem.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
518. ExplanationOfBenefit.addItem.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
520. ExplanationOfBenefit.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
522. ExplanationOfBenefit.addItem.itemSequence
Definition | Claim items which this service line is intended to replace.
Short | Item sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
524. ExplanationOfBenefit.addItem.detailSequence
Definition | The sequence number of the details within the claim item which this line is intended to replace.
Short | Detail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
526. ExplanationOfBenefit.addItem.subDetailSequence
Definition | The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
Short | Subdetail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
528. ExplanationOfBenefit.addItem.provider
Definition | The providers who are authorized for the services rendered to the patient.
Short | Authorized providers
Control | 0..*
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
530. ExplanationOfBenefit.addItem.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
532. ExplanationOfBenefit.addItem.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
534. ExplanationOfBenefit.addItem.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
536. ExplanationOfBenefit.addItem.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Short | Date or dates of service or product delivery
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
538. ExplanationOfBenefit.addItem.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place|4.0.1` ) Place where the service is rendered.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
540. ExplanationOfBenefit.addItem.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
542. ExplanationOfBenefit.addItem.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
544. ExplanationOfBenefit.addItem.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
546. ExplanationOfBenefit.addItem.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
548. ExplanationOfBenefit.addItem.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical location
Comments | For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
550. ExplanationOfBenefit.addItem.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
552. ExplanationOfBenefit.addItem.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
554. ExplanationOfBenefit.addItem.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
556. ExplanationOfBenefit.addItem.detail
Definition | The second-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
558. ExplanationOfBenefit.addItem.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
560. ExplanationOfBenefit.addItem.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
562. ExplanationOfBenefit.addItem.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
564. ExplanationOfBenefit.addItem.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
566. ExplanationOfBenefit.addItem.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
568. ExplanationOfBenefit.addItem.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
570. ExplanationOfBenefit.addItem.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
572. ExplanationOfBenefit.addItem.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
574. ExplanationOfBenefit.addItem.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
576. ExplanationOfBenefit.addItem.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
578. ExplanationOfBenefit.addItem.detail.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
580. ExplanationOfBenefit.addItem.detail.subDetail
Definition | The third-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
582. ExplanationOfBenefit.addItem.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
584. ExplanationOfBenefit.addItem.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
586. ExplanationOfBenefit.addItem.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
588. ExplanationOfBenefit.addItem.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
590. ExplanationOfBenefit.addItem.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
592. ExplanationOfBenefit.addItem.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
594. ExplanationOfBenefit.addItem.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
596. ExplanationOfBenefit.addItem.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
598. ExplanationOfBenefit.addItem.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
600. ExplanationOfBenefit.addItem.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
602. ExplanationOfBenefit.addItem.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
604. 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: value @ category
606. ExplanationOfBenefit.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
608. ExplanationOfBenefit.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
610. ExplanationOfBenefit.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
612. ExplanationOfBenefit.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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())`)
614. ExplanationOfBenefit.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
616. ExplanationOfBenefit.adjudication.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
618. ExplanationOfBenefit.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
620. 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())`)
622. ExplanationOfBenefit.adjudication:medicalmanagement.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
624. ExplanationOfBenefit.adjudication:medicalmanagement.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.adjudication.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
626. 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
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()`)
628. ExplanationOfBenefit.adjudication:medicalmanagement.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
630. ExplanationOfBenefit.adjudication:medicalmanagement.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "medicalmanagement" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
632. ExplanationOfBenefit.adjudication:medicalmanagement.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
634. 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..0
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())`)
636. 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..0
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())`)
638. 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 Status
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())`)
640. ExplanationOfBenefit.adjudication:billingnetworkstatus.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
642. ExplanationOfBenefit.adjudication:billingnetworkstatus.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
644. ExplanationOfBenefit.adjudication:billingnetworkstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
646. ExplanationOfBenefit.adjudication:billingnetworkstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "billingnetworkstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
648. ExplanationOfBenefit.adjudication:billingnetworkstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Payer Benefit Payment Status (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())`)
650. ExplanationOfBenefit.adjudication:billingnetworkstatus.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
652. ExplanationOfBenefit.adjudication:billingnetworkstatus.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
654. 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 Status
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())`)
656. ExplanationOfBenefit.adjudication:renderingnetworkstatus.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
658. ExplanationOfBenefit.adjudication:renderingnetworkstatus.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
660. ExplanationOfBenefit.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()`)
662. ExplanationOfBenefit.adjudication:renderingnetworkstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "renderingnetworkstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
664. ExplanationOfBenefit.adjudication:renderingnetworkstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Payer Benefit Payment Status (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())`)
666. ExplanationOfBenefit.adjudication:renderingnetworkstatus.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
668. ExplanationOfBenefit.adjudication:renderingnetworkstatus.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
670. 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 Status
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())`)
672. ExplanationOfBenefit.adjudication:benefitpaymentstatus.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
674. ExplanationOfBenefit.adjudication:benefitpaymentstatus.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
676. ExplanationOfBenefit.adjudication:benefitpaymentstatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
678. ExplanationOfBenefit.adjudication:benefitpaymentstatus.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "benefitpaymentstatus" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
680. ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Payer Benefit Payment Status (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())`)
682. ExplanationOfBenefit.adjudication:benefitpaymentstatus.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
684. ExplanationOfBenefit.adjudication:benefitpaymentstatus.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
686. 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 Reason
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())`)
688. ExplanationOfBenefit.adjudication:adjustmentreason.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
690. ExplanationOfBenefit.adjudication:adjustmentreason.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
692. ExplanationOfBenefit.adjudication:adjustmentreason.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
694. ExplanationOfBenefit.adjudication:adjustmentreason.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "adjustmentreason" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
696. ExplanationOfBenefit.adjudication:adjustmentreason.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
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 PCT Adjustment 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())`)
698. ExplanationOfBenefit.adjudication:adjustmentreason.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
700. ExplanationOfBenefit.adjudication:adjustmentreason.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
702. 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 amount
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())`)
704. ExplanationOfBenefit.adjudication:submitted.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
706. ExplanationOfBenefit.adjudication:submitted.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
708. ExplanationOfBenefit.adjudication:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
710. ExplanationOfBenefit.adjudication:submitted.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
712. ExplanationOfBenefit.adjudication:submitted.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
714. ExplanationOfBenefit.adjudication:submitted.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
716. ExplanationOfBenefit.adjudication:submitted.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
718. 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 liability
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())`)
720. ExplanationOfBenefit.adjudication:memberliability.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
722. ExplanationOfBenefit.adjudication:memberliability.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
724. ExplanationOfBenefit.adjudication:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
726. ExplanationOfBenefit.adjudication:memberliability.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
728. ExplanationOfBenefit.adjudication:memberliability.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
730. ExplanationOfBenefit.adjudication:memberliability.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
732. ExplanationOfBenefit.adjudication:memberliability.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
734. 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 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
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())`)
736. ExplanationOfBenefit.adjudication:eligible.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
738. ExplanationOfBenefit.adjudication:eligible.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
740. ExplanationOfBenefit.adjudication:eligible.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
742. ExplanationOfBenefit.adjudication:eligible.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
744. ExplanationOfBenefit.adjudication:eligible.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
746. ExplanationOfBenefit.adjudication:eligible.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
748. ExplanationOfBenefit.adjudication:eligible.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
750. 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 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
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())`)
752. ExplanationOfBenefit.adjudication:benefit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
754. ExplanationOfBenefit.adjudication:benefit.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
756. ExplanationOfBenefit.adjudication:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
758. ExplanationOfBenefit.adjudication:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT GFE Item Adjudication Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
760. ExplanationOfBenefit.adjudication:benefit.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example, may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) Adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
762. ExplanationOfBenefit.adjudication:benefit.amount
Definition | Monetary amount associated with the category.
Short | Monetary amount
Comments | For example, amount submitted, eligible amount, co-payment, and benefit payable.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
764. ExplanationOfBenefit.adjudication:benefit.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monitary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
766. ExplanationOfBenefit.total
Definition | Categorized monetary totals for the adjudication.
Short | Adjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 3..*
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: value @ category
768. ExplanationOfBenefit.total.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
770. ExplanationOfBenefit.total.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
772. ExplanationOfBenefit.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
774. ExplanationOfBenefit.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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())`)
776. 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())`)
778. ExplanationOfBenefit.total:submitted
Slice Name | submitted
Definition | Categorized monetary totals for the adjudication.
Short | Total provider submitted amount
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 1..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())`)
780. ExplanationOfBenefit.total:submitted.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
782. ExplanationOfBenefit.total:submitted.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
784. ExplanationOfBenefit.total:submitted.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
786. ExplanationOfBenefit.total:submitted.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
788. ExplanationOfBenefit.total:submitted.amount
Definition | Monetary total amount associated with the category.
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())`)
790. ExplanationOfBenefit.total:memberliability
Slice Name | memberliability
Definition | Categorized monetary totals for the adjudication.
Short | Total member liability
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 1..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())`)
792. ExplanationOfBenefit.total:memberliability.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
794. ExplanationOfBenefit.total:memberliability.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
796. ExplanationOfBenefit.total:memberliability.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
798. ExplanationOfBenefit.total:memberliability.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
800. ExplanationOfBenefit.total:memberliability.amount
Definition | Monetary total amount associated with the category.
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())`)
802. ExplanationOfBenefit.total:eligible
Slice Name | eligible
Definition | Categorized monetary totals for the adjudication.
Short | Total 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 | 1..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())`)
804. ExplanationOfBenefit.total:eligible.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
806. ExplanationOfBenefit.total:eligible.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
808. ExplanationOfBenefit.total:eligible.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
810. ExplanationOfBenefit.total:eligible.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
812. ExplanationOfBenefit.total:eligible.amount
Definition | Monetary total amount associated with the category.
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())`)
814. ExplanationOfBenefit.total:innetwork
Slice Name | innetwork
Definition | Categorized monetary totals for the adjudication.
Short | Total in network amount - only include when total type is applicable
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())`)
816. ExplanationOfBenefit.total:innetwork.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
818. ExplanationOfBenefit.total:innetwork.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
820. ExplanationOfBenefit.total:innetwork.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
822. ExplanationOfBenefit.total:innetwork.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "innetwork" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
824. ExplanationOfBenefit.total:innetwork.amount
Definition | Monetary total amount associated with the category.
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())`)
826. ExplanationOfBenefit.total:outofnetwork
Slice Name | outofnetwork
Definition | Categorized monetary totals for the adjudication.
Short | Total out of network amount - only include when total type is applicable
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())`)
828. ExplanationOfBenefit.total:outofnetwork.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
830. ExplanationOfBenefit.total:outofnetwork.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
832. ExplanationOfBenefit.total:outofnetwork.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
834. ExplanationOfBenefit.total:outofnetwork.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "outofnetwork" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
836. ExplanationOfBenefit.total:outofnetwork.amount
Definition | Monetary total amount associated with the category.
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())`)
838. ExplanationOfBenefit.total:noncovered
Slice Name | noncovered
Definition | Categorized monetary totals for the adjudication.
Short | Total noncovered amount - only include when total type is applicable
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())`)
840. ExplanationOfBenefit.total:noncovered.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
842. ExplanationOfBenefit.total:noncovered.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
844. ExplanationOfBenefit.total:noncovered.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
846. ExplanationOfBenefit.total:noncovered.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication", "code" : "noncovered" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
848. ExplanationOfBenefit.total:noncovered.amount
Definition | Monetary total amount associated with the category.
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())`)
850. ExplanationOfBenefit.total:negotiated
Slice Name | negotiated
Definition | Categorized monetary totals for the adjudication.
Short | Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
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())`)
852. ExplanationOfBenefit.total:negotiated.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
854. ExplanationOfBenefit.total:negotiated.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
856. ExplanationOfBenefit.total:negotiated.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
858. ExplanationOfBenefit.total:negotiated.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "negotiated" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
860. ExplanationOfBenefit.total:negotiated.amount
Definition | Monetary total amount associated with the category.
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())`)
862. ExplanationOfBenefit.total:benefit
Slice Name | benefit
Definition | Categorized monetary totals for the adjudication.
Short | Total benefit amount - only include when total type is applicable
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 | 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())`)
864. ExplanationOfBenefit.total:benefit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
866. ExplanationOfBenefit.total:benefit.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
868. ExplanationOfBenefit.total:benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
870. ExplanationOfBenefit.total:benefit.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
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 PCT Total Value Set (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.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
872. ExplanationOfBenefit.total:benefit.amount
Definition | Monetary total amount associated with the category.
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())`)
874. ExplanationOfBenefit.payment
Definition | Payment details for the adjudication of the claim.
Short | Payment Details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
876. ExplanationOfBenefit.payment.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
878. ExplanationOfBenefit.payment.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
880. ExplanationOfBenefit.payment.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
882. ExplanationOfBenefit.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Short | Partial or complete payment
Control | 0..1
Binding | For example codes, see ExamplePaymentTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1` ) The type (partial, complete) of the payment.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
884. ExplanationOfBenefit.payment.adjustment
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Short | Payment adjustment for non-claim issues
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | To advise the requestor of adjustments applied to the payment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
886. ExplanationOfBenefit.payment.adjustmentReason
Definition | Reason for the payment adjustment.
Short | Explanation for the variance
Control | 0..1
Binding | For example codes, see PaymentAdjustmentReasonCodes (example to `http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1` ) Payment Adjustment reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to clarify the monetary adjustment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
888. ExplanationOfBenefit.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Short | Expected date of payment
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To advise the payee when payment can be expected.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
890. ExplanationOfBenefit.payment.amount
Definition | Benefits payable less any payment adjustment.
Short | Payable amount after adjustment
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Needed to provide the actual payment amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
892. ExplanationOfBenefit.payment.identifier
Definition | Issuer's unique identifier for the payment instrument.
Short | Business identifier for the payment
Comments | For example: EFT number or check number.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Enable the receiver to reconcile when payment received.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
894. ExplanationOfBenefit.formCode
Definition | A code for the form to be used for printing the content.
Short | Printed form identifier
Comments | May be needed to identify specific jurisdictional forms.
Control | 0..1
Binding | For example codes, see Form Codes (example to `http://hl7.org/fhir/ValueSet/forms|4.0.1` ) The forms codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to specify the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
896. ExplanationOfBenefit.form
Definition | The actual form, by reference or inclusion, for printing the content or an EOB.
Short | Printed reference or actual form
Comments | Needed to permit insurers to include the actual form.
Control | 0..1
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Needed to include the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
898. 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 possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
Comments | These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
Control | 1..*
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())`)
900. ExplanationOfBenefit.processNote.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
902. ExplanationOfBenefit.processNote.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.processNote.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
904. 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
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()`)
906. ExplanationOfBenefit.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
908. ExplanationOfBenefit.processNote.number
Definition | A number to uniquely identify a note entry.
Short | Note instance identifier
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link from adjudications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
910. ExplanationOfBenefit.processNote.type
Definition | The business purpose of the note text.
Short | display | print | printoper
Control | 0..1
Binding | The codes SHALL be taken from NoteType (required to `http://hl7.org/fhir/ValueSet/note-type|4.0.1` ) The presentation types of notes.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the expectation for when the text is used.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
912. ExplanationOfBenefit.processNote.text
Definition | The explanation or description associated with the processing.
Short | Note explanatory text
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required to provide human readable explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
914. ExplanationOfBenefit.processNote.language
Definition | A code to define the language used in the text of the note.
Short | Language of the text
Comments | Only required if the language is different from the resource language.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Note text may vary from the resource defined language.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
916. 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 | 1..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())`)
918. ExplanationOfBenefit.benefitBalance
Definition | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.
Short | Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
Control | 1..*
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())`)
920. ExplanationOfBenefit.benefitBalance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
922. ExplanationOfBenefit.benefitBalance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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()`)
924. ExplanationOfBenefit.benefitBalance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
926. 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 PCT benefitBalance.category codes (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())`)
928. ExplanationOfBenefit.benefitBalance.category.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
930. ExplanationOfBenefit.benefitBalance.category.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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.benefitBalance.category.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
932. ExplanationOfBenefit.benefitBalance.category.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
934. ExplanationOfBenefit.benefitBalance.category.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
936. ExplanationOfBenefit.benefitBalance.excluded
Definition | True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Short | Excluded from the plan
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to identify items that are specifically excluded from the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
938. ExplanationOfBenefit.benefitBalance.name
Definition | A short name or tag for the benefit.
Short | Short name for the benefit
Comments | For example: MED01, or DENT2.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required to align with other plan names.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
940. ExplanationOfBenefit.benefitBalance.description
Definition | A richer description of the benefit or services covered.
Short | Description of the benefit or services covered
Comments | For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed for human readable reference.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
942. ExplanationOfBenefit.benefitBalance.network
Definition | Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Short | In or out of network
Control | 0..1
Binding | For example codes, see NetworkTypeCodes (example to `http://hl7.org/fhir/ValueSet/benefit-network|4.0.1` ) Code to classify in or out of network services.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed as in or out of network providers are treated differently under the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
944. ExplanationOfBenefit.benefitBalance.unit
Definition | Indicates if the benefits apply to an individual or to the family.
Short | Individual or family
Control | 1..1
Binding | The codes SHALL be taken from UnitTypeCodes (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())`)
946. 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 | 1..1
Binding | The codes SHALL be taken from BenefitTermCodes (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())`)
948. ExplanationOfBenefit.benefitBalance.financial
Definition | Benefits Used to date.
Short | Benefit Summary
Control | 1..*
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())`)
950. ExplanationOfBenefit.benefitBalance.financial.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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
952. ExplanationOfBenefit.benefitBalance.financial.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
954. ExplanationOfBenefit.benefitBalance.financial.extension:remaining
Slice 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
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()`)
956. ExplanationOfBenefit.benefitBalance.financial.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
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()`)
958. 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 PCT Financial Type Value Set (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())`)
960. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 1..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 offered under the coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
962. ExplanationOfBenefit.benefitBalance.financial.used[x]
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 1..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())`)