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: PCTAdvancedEOBSummary - Detailed Descriptions

Page standards status: Trial-use | Maturity Level: 1

Definitions for the davinci-pct-aeob-summary 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())
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 | 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.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. 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
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())
8. 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())
10. 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())
12. 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()))
14. 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 | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse", "code" : "estimate-summary" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. 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..01
Binding | For example codes, see ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1 (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()))
18. 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()))
20. 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()))
22. ExplanationOfBenefit.billablePeriod
Definition | The period for which charges are being submitted.
Short | The full Period of Care for all services or products included in the estimate from the first event to the last event.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 | 10..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()))
24. ExplanationOfBenefit.created
Definition | The date this resource was created.
Short | The date and time this summary was generated.Response creation date
Comments | The date and time this summary was generated 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()))
26. ExplanationOfBenefit.enterer
Definition | Individual who created the claim, predetermination or preauthorization.
Short | Author of the claim
Control | 0..01
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()))
28. 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()))
30. 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(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()))
32. ExplanationOfBenefit.provider.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.provider.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
34. ExplanationOfBenefit.provider.extension:dataAbsentReason
Slice Name | dataAbsentReason
Definition | Provides a reason why the expected value or elements in the element that is extended are missing.
Short | unknown | asked | temp | notasked | masked | unsupported | astext | error
Control | 1..1
Type | Extension(Data Absent Reason) (Extension Type: code)
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())
36. ExplanationOfBenefit.provider.extension:dataAbsentReason.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..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()`) 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.provider.extension.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
38. ExplanationOfBenefit.provider.extension:dataAbsentReason.url
Definition | Source of the definition for the extension code - a logical name or a URL.
Short | identifies the meaning of the extension
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Control | 1..1
Type | uri
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
Fixed Value | `http://hl7.org/fhir/StructureDefinition/data-absent-reason`
40. ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Short | Value of extension
Control | 10..1 This element is affected by the following invariants: ext-1
Binding | The codes SHALL be taken from For codes, see DataAbsentReason (required to `http://hl7.org/fhir/ValueSet/data-absent-reason` )
Type | code, date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, Reference, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time
[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
Pattern Value | `not-applicable`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ExplanationOfBenefit.provider.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..01 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()))
44. ExplanationOfBenefit.provider.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..01
Binding | Unless not suitable, these codes SHALL be taken from ResourceType http://hl7.org/fhir/ValueSet/resource-types|4.0.1 (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()))
46. ExplanationOfBenefit.provider.identifier
Definition | 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 | Logical 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 | 0..01
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ExplanationOfBenefit.provider.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..01
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()))
50. 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
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()))
52. 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..01
Binding | For example codes, see Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1 (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()))
54. 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..01
Binding | For example codes, see Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1 (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()))
56. ExplanationOfBenefit.prescription
Definition | Prescription to support the dispensing of pharmacy, device or vision products.
Short | Prescription authorizing services or products
Control | 0..01
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()))
58. 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..01
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()))
60. 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..01
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()))
63. 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..01
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()))
65. ExplanationOfBenefit.facility
Definition | Facility where the services were provided.
Short | Servicing Facility
Control | 0..01
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()))
67. ExplanationOfBenefit.claim
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
Short | Claim reference
Control | 0..01
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()))
69. 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()))
71. 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..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()))
73. 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..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()))
75. 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..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()))
80. 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..01
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()))
82. 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()))
84. 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())
86. 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()))
88. 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()))
90. 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 | 0..0*
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()))
95. ExplanationOfBenefit.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..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()))
99. 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..0*
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
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()))
101. 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
103. 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())
105. 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()))
107. 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()))
109. 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()))
111. 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())
113. 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()))
115. 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()))
117. 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()))
119. 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())
121. 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()))
123. 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()))
125. 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()))
127. 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())
129. 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()))
131. 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()))
133. 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()))
135. 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())
137. 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()))
139. 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()))
141. 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()))
143. 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())
145. 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()))
147. 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()))
149. 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()))
151. 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())
153. 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()))
155. 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()))
157. 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()))
159. 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())
161. 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()))
163. 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()))
165. 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()))
167. 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())
169. 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()))
171. 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()))
173. ExplanationOfBenefit.payment
Definition | Payment details for the adjudication of the claim.
Short | Payment Details
Control | 0..01
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()))
176. 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()))
178. 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
180. 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())
182. 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())
184. 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()))
186. 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()))
188. 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())
190. 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()))
192. 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()))
194. 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()))
196. 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()))
198. 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()))
200. 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
202. 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())
204. 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())
206. 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()))
208. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 10..1
Type | Money, string, unsignedInt
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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()))
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.allowed[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
210. ExplanationOfBenefit.benefitBalance.financial.allowed[x]:allowedMoney
Slice Name | allowedMoney
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 10..1
Type | Money, string, unsignedInt
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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()))
212. ExplanationOfBenefit.benefitBalance.financial.used[x]
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 10..1
Type | Money, unsignedInt
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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()))
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.used[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
214. ExplanationOfBenefit.benefitBalance.financial.used[x]:usedMoney
Slice Name | usedMoney
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 10..1
Type | Money, unsignedInt
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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
2. ExplanationOfBenefit.extension
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:serviceDescription
Slice Name | serviceDescription
Control | 0..1
Type | Extension(Service Description) (Extension Type: string)
Must Support | true
6. ExplanationOfBenefit.extension:outOfNetworkProviderInfo
Slice Name | outOfNetworkProviderInfo
Control | 0..1
Type | Extension(In Network Provider Options Link) (Extension Type: url)
Must Support | true
8. ExplanationOfBenefit.type
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse", "code" : "estimate-summary" }] }`
10. ExplanationOfBenefit.subType
Control | 0..0
12. ExplanationOfBenefit.use
Pattern Value | `predetermination`
14. ExplanationOfBenefit.patient
Type | Reference(US Core Patient Profile)
16. ExplanationOfBenefit.billablePeriod
Short | The full Period of Care for all services or products included in the estimate from the first event to the last event.
Control | 1..?
18. ExplanationOfBenefit.created
Short | The date and time this summary was generated.
Comments | The date and time this summary was generated based on what was known at that point in time.
20. ExplanationOfBenefit.enterer
Control | 0..0
22. ExplanationOfBenefit.insurer
Type | Reference(PCT Organization)
24. ExplanationOfBenefit.provider
26. ExplanationOfBenefit.provider.extension
Control | 1..?
28. ExplanationOfBenefit.provider.extension:dataAbsentReason
Slice Name | dataAbsentReason
Control | 1..1
Type | Extension(Data Absent Reason) (Extension Type: code)
30. ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Pattern Value | `not-applicable`
32. ExplanationOfBenefit.provider.reference
Control | 0..0
34. ExplanationOfBenefit.provider.type
Control | 0..0
36. ExplanationOfBenefit.provider.identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..0
38. ExplanationOfBenefit.provider.display
Control | 0..0
40. ExplanationOfBenefit.priority
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
42. ExplanationOfBenefit.fundsReserveRequested
Control | 0..0
44. ExplanationOfBenefit.fundsReserve
Control | 0..0
46. ExplanationOfBenefit.prescription
Control | 0..0
48. ExplanationOfBenefit.originalPrescription
Control | 0..0
50. ExplanationOfBenefit.payee
Control | 0..0
52. ExplanationOfBenefit.referral
Control | 0..0
54. ExplanationOfBenefit.facility
Control | 0..0
56. ExplanationOfBenefit.claim
Control | 0..0
58. ExplanationOfBenefit.preAuthRef
Control | 0..0
60. ExplanationOfBenefit.preAuthRefPeriod
Control | 0..0
62. ExplanationOfBenefit.supportingInfo
Control | 0..0
64. ExplanationOfBenefit.precedence
Control | 0..0
66. ExplanationOfBenefit.insurance
68. ExplanationOfBenefit.insurance.coverage
Type | Reference(PCT Coverage)
70. ExplanationOfBenefit.item
Control | 0..0
72. ExplanationOfBenefit.addItem
Control | 0..0
74. ExplanationOfBenefit.adjudication
Control | 0..0
76. 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
78. 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
80. ExplanationOfBenefit.total:submitted
Slice Name | submitted
Short | Total provider submitted amount
Control | 1..1
Must Support | true
82. ExplanationOfBenefit.total:submitted.category
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "submitted" }] }`
84. ExplanationOfBenefit.total:memberliability
Slice Name | memberliability
Short | Total member liability
Control | 1..1
Must Support | true
86. ExplanationOfBenefit.total:memberliability.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS", "code" : "memberliability" }] }`
88. 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
90. ExplanationOfBenefit.total:eligible.category
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "eligible" }] }`
92. ExplanationOfBenefit.total:innetwork
Slice Name | innetwork
Short | Total in network amount - only include when total type is applicable
Control | 0..1
Must Support | true
94. ExplanationOfBenefit.total:innetwork.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "innetwork" }] }`
96. 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
98. ExplanationOfBenefit.total:outofnetwork.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "outofnetwork" }] }`
100. ExplanationOfBenefit.total:noncovered
Slice Name | noncovered
Short | Total noncovered amount - only include when total type is applicable
Control | 0..1
Must Support | true
102. ExplanationOfBenefit.total:noncovered.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication", "code" : "noncovered" }] }`
104. 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
106. ExplanationOfBenefit.total:negotiated.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS", "code" : "negotiated" }] }`
108. 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
110. ExplanationOfBenefit.total:benefit.category
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/adjudication", "code" : "benefit" }] }`
112. ExplanationOfBenefit.payment
Control | 0..0
114. 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..?
116. 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
118. ExplanationOfBenefit.processNote.extension:processNoteClass
Slice Name | processNoteClass
Control | 0..1
Type | Extension(ProcessNote Class) (Extension Type: CodeableConcept)
120. ExplanationOfBenefit.benefitPeriod
Control | 1..?
122. 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..?
124. 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` )
126. ExplanationOfBenefit.benefitBalance.category.text
Control | 1..?
Must Support | true
128. ExplanationOfBenefit.benefitBalance.unit
Control | 1..?
Binding | The codes SHALL be taken from UnitTypeCodes (required to `http://hl7.org/fhir/ValueSet/benefit-unit` )
130. ExplanationOfBenefit.benefitBalance.term
Control | 1..?
Binding | The codes SHALL be taken from BenefitTermCodes (required to `http://hl7.org/fhir/ValueSet/benefit-term` )
132. ExplanationOfBenefit.benefitBalance.financial
Control | 1..?
134. 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
136. ExplanationOfBenefit.benefitBalance.financial.extension:remaining
Slice Name | remaining
Control | 0..1
Type | Extension(Benefit Remaining) (Extension Type: Choice of: unsignedInt, Money)
Must Support | true
138. 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` )
140. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Control | 1..?
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.allowed[x]`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ $this
142. ExplanationOfBenefit.benefitBalance.financial.allowed[x]:allowedMoney
Slice Name | allowedMoney
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
144. ExplanationOfBenefit.benefitBalance.financial.used[x]
Control | 1..?
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.used[x]`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ $this
146. ExplanationOfBenefit.benefitBalance.financial.used[x]:usedMoney
Slice Name | usedMoney
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]

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()`)
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 | 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.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. 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
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()`)
18. 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()`)
20. 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()`)
22. 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 | 0..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows EOBs to be distinguished and referenced.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. 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())`)
26. 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 | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTEstimateTypeSummaryCSTemporaryTrialUse", "code" : "estimate-summary" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. 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..0
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())`)
30. 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())`)
32. 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())`)
34. ExplanationOfBenefit.billablePeriod
Definition | The period for which charges are being submitted.
Short | The full Period of Care for all services or products included in the estimate from the first event to the last event.
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 | 1..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())`)
36. ExplanationOfBenefit.created
Definition | The date this resource was created.
Short | The date and time this summary was generated.
Comments | The date and time this summary was generated 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())`)
38. ExplanationOfBenefit.enterer
Definition | Individual who created the claim, predetermination or preauthorization.
Short | Author of the claim
Control | 0..0
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())`)
40. 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())`)
42. 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(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())`)
44. ExplanationOfBenefit.provider.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
46. ExplanationOfBenefit.provider.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.provider.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
48. ExplanationOfBenefit.provider.extension:dataAbsentReason
Slice Name | dataAbsentReason
Definition | Provides a reason why the expected value or elements in the element that is extended are missing.
Short | unknown | asked | temp | notasked | masked | unsupported | astext | error
Control | 1..1
Type | Extension(Data Absent Reason) (Extension Type: code)
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()`)
50. ExplanationOfBenefit.provider.extension:dataAbsentReason.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 This element is affected by the following invariants: ele-1
Type | id
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
52. ExplanationOfBenefit.provider.extension:dataAbsentReason.extension
Definition | An Extension
Short | Extension
Control | 0..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.provider.extension.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
54. ExplanationOfBenefit.provider.extension:dataAbsentReason.url
Definition | Source of the definition for the extension code - a logical name or a URL.
Short | identifies the meaning of the extension
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
Control | 1..1
Type | uri
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
Fixed Value | `http://hl7.org/fhir/StructureDefinition/data-absent-reason`
56. ExplanationOfBenefit.provider.extension:dataAbsentReason.value[x]
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Short | Value of extension
Control | 1..1 This element is affected by the following invariants: ext-1
Binding | The codes SHALL be taken from DataAbsentReason (required to `http://hl7.org/fhir/ValueSet/data-absent-reason` )
Type | code
[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
Pattern Value | `not-applicable`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. ExplanationOfBenefit.provider.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..0 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())`)
60. ExplanationOfBenefit.provider.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..0
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())`)
62. ExplanationOfBenefit.provider.identifier
Definition | 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 | Logical 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 | 0..0
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())`)
64. ExplanationOfBenefit.provider.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..0
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())`)
66. 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
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())`)
68. 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..0
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())`)
70. 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..0
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())`)
72. 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())`)
74. 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
76. 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()`)
78. 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()`)
80. 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())`)
82. 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())`)
84. 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())`)
86. ExplanationOfBenefit.prescription
Definition | Prescription to support the dispensing of pharmacy, device or vision products.
Short | Prescription authorizing services or products
Control | 0..0
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())`)
88. 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..0
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())`)
90. 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..0
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())`)
97. 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..0
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())`)
99. ExplanationOfBenefit.facility
Definition | Facility where the services were provided.
Short | Servicing Facility
Control | 0..0
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())`)
101. ExplanationOfBenefit.claim
Definition | The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
Short | Claim reference
Control | 0..0
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())`)
103. 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())`)
105. 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())`)
107. 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())`)
109. 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..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())`)
111. 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..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())`)
113. 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())`)
115. 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
117. 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()`)
119. 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()`)
121. 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())`)
123. 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())`)
125. 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())`)
127. 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())`)
129. 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())`)
131. 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..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())`)
142. 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())`)
144. 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
146. 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()`)
148. 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()`)
150. 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())`)
152. 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())`)
154. 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())`)
156. 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())`)
158. 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())`)
160. 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())`)
162. 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
164. 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()`)
166. 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()`)
168. 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())`)
170. 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())`)
172. 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())`)
174. 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())`)
176. 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())`)
178. 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..0
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())`)
180. 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())`)
182. 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
184. 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()`)
186. 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()`)
188. 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())`)
190. 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())`)
192. 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())`)
194. 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())`)
196. 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
198. 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()`)
200. 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()`)
202. 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())`)
204. 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())`)
206. 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())`)
208. 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 | 0..0
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())`)
276. ExplanationOfBenefit.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..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())`)
322. 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..0
Type | Seettp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit#ExplanationOfBenefit.item.adjudication
Is Modifier | false
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())`)
324. 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
326. 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
328. 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()`)
330. 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()`)
332. 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())`)
334. 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())`)
336. 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())`)
338. 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
340. 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()`)
342. 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()`)
344. 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())`)
346. 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())`)
348. 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())`)
350. 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
352. 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()`)
354. 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()`)
356. 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())`)
358. 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())`)
360. 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())`)
362. 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
364. 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()`)
366. 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()`)
368. 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())`)
370. 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())`)
372. 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())`)
374. 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
376. 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()`)
378. 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()`)
380. 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())`)
382. 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())`)
384. 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())`)
386. 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
388. 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()`)
390. 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()`)
392. 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())`)
394. 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())`)
396. 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())`)
398. 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
400. 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()`)
402. 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()`)
404. 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())`)
406. 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())`)
408. 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())`)
410. 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
412. 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()`)
414. 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()`)
416. 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())`)
418. 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())`)
420. 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())`)
422. 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
424. 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()`)
426. 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()`)
428. 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())`)
430. 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())`)
432. ExplanationOfBenefit.payment
Definition | Payment details for the adjudication of the claim.
Short | Payment Details
Control | 0..0
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())`)
443. 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())`)
445. 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())`)
447. 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())`)
449. 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
451. 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
453. 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()`)
455. 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()`)
457. 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())`)
459. 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())`)
461. 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())`)
463. 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())`)
465. 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())`)
467. 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())`)
469. 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
471. 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()`)
473. 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()`)
475. 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())`)
477. 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
479. 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
481. 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())`)
483. 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())`)
485. 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())`)
487. 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())`)
489. 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())`)
491. 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())`)
493. 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())`)
495. 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())`)
497. 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())`)
499. 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
501. 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
503. 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()`)
505. 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()`)
507. 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())`)
509. ExplanationOfBenefit.benefitBalance.financial.allowed[x]
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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())`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.allowed[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
511. ExplanationOfBenefit.benefitBalance.financial.allowed[x]:allowedMoney
Slice Name | allowedMoney
Definition | The quantity of the benefit which is permitted under the coverage.
Short | Benefits allowed
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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())`)
513. ExplanationOfBenefit.benefitBalance.financial.used[x]
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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())`)
Slicing | This element introduces a set of slices on `ExplanationOfBenefit.benefitBalance.financial.used[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
515. ExplanationOfBenefit.benefitBalance.financial.used[x]:usedMoney
Slice Name | usedMoney
Definition | The quantity of the benefit which have been consumed to date.
Short | Benefits used
Control | 1..1
Type | Money
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
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())`)