DHIN 2025Connectathon FHIR IG
0.1.0 - draft
DHIN 2025Connectathon FHIR IG, published by DHIN. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Nigeria-FHIR-Community/2025Connectathon/ and changes regularly. See the Directory of published versions
Official URL: https://sandbox.dhin-hie.org/ig/StructureDefinition/ng-explanationofbenefit | Version: 0.1.0 | |||
Draft as of 2025-10-02 | Computable Name: NgExplanationOfBenefit |
A profile detailing adjudicated claim results.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
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SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. |
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SΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
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SΣ | 1..1 | dateTime | Response creation date |
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SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
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Σ | 1..* | BackboneElement | Patient insurance information |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | boolean | Coverage to be used for adjudication |
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Σ | 1..1 | Reference(Coverage) | Insurance information |
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Path | Status | Usage | ValueSet | Version | Source |
ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
Id | Grade | Path(s) | Description | Expression |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
dom-3 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management |
text.`div`.exists()
|
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
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S | 1..1 | code | active | cancelled | draft | entered-in-error |
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S | 1..1 | CodeableConcept | Category or discipline |
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S | 1..1 | Reference(Patient) | The recipient of the products and services |
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S | 1..1 | dateTime | Response creation date |
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S | 1..1 | Reference(Organization) | Party responsible for reimbursement |
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Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
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0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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0..* | Identifier | Business Identifier for the resource | |||||
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?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
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0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. | ||||
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SΣ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
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Σ | 0..1 | Period | Relevant time frame for the claim | ||||
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SΣ | 1..1 | dateTime | Response creation date | ||||
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0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
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SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | |||||
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0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
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0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
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0..1 | BackboneElement | Recipient of benefits payable | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
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0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
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0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
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0..1 | Reference(Location) | Servicing Facility | |||||
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0..1 | Reference(Claim) | Claim reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
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Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | string | Preauthorization reference | |||||
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0..* | Period | Preauthorization in-effect period | |||||
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0..* | BackboneElement | Care Team members | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Order of care team | |||||
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1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
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0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
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0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Supporting information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Information instance identifier | |||||
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1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
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0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
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0..1 | When it occurred | ||||||
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date | |||||||
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Period | |||||||
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0..1 | Data to be provided | ||||||
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boolean | |||||||
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string | |||||||
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Quantity | |||||||
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Attachment | |||||||
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Reference(Resource) | |||||||
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0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
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0..* | BackboneElement | Pertinent diagnosis information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Diagnosis instance identifier | |||||
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1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
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CodeableConcept | |||||||
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Reference(Condition) | |||||||
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0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
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0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Procedure instance identifier | |||||
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0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
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0..1 | dateTime | When the procedure was performed | |||||
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1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
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Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
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Σ | 1..* | BackboneElement | Patient insurance information | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
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Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | BackboneElement | Details of the event | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | date | When the incident occurred | |||||
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0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
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0..1 | Where the event occurred | ||||||
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Address | |||||||
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Reference(Location) | |||||||
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0..* | BackboneElement | Product or service provided | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Item instance identifier | |||||
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0..* | positiveInt | Applicable care team members | |||||
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0..* | positiveInt | Applicable diagnoses | |||||
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0..* | positiveInt | Applicable procedures | |||||
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0..* | positiveInt | Applicable exception and supporting information | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
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1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
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0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
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0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | Date or dates of service or product delivery | ||||||
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date | |||||||
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Period | |||||||
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0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
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CodeableConcept | |||||||
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Address | |||||||
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Reference(Location) | |||||||
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0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
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0..1 | Money | Fee, charge or cost per item | |||||
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0..1 | decimal | Price scaling factor | |||||
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0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
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0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
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0..* | Reference(Encounter) | Encounters related to this billed item | |||||
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0..* | positiveInt | Applicable note numbers | |||||
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0..* | BackboneElement | Adjudication details | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
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0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
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0..1 | Money | Monetary amount | |||||
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0..1 | decimal | Non-monitary value | |||||
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0..* | BackboneElement | Additional items | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Product or service provided | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
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1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
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0..1 | decimal | Price scaling factor | |||||
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0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..* | positiveInt | Applicable note numbers | |||||
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0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
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0..* | BackboneElement | Additional items | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Product or service provided | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
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1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..* | positiveInt | Applicable note numbers | |||||
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0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
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0..* | BackboneElement | Insurer added line items | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Item sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Detail sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Subdetail sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | Date or dates of service or product delivery | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Insurer added line items | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | BackboneElement | Insurer added line items | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |||||
![]() ![]() ![]() |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
![]() ![]() ![]() |
0..1 | BackboneElement | Payment Details | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Payment adjustment for non-claim issues | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | date | Expected date of payment | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Payable amount after adjustment | |||||
![]() ![]() ![]() ![]() |
0..1 | Identifier | Business identifier for the payment | |||||
![]() ![]() ![]() |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
![]() ![]() ![]() |
0..1 | Attachment | Printed reference or actual form | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Note concerning adjudication | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | positiveInt | Note instance identifier | |||||
![]() ![]() ![]() ![]() |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Note explanatory text | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Period | When the benefits are applicable | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Balance by Benefit Category | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Excluded from the plan | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Short name for the benefit | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Description of the benefit or services covered | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Benefit Summary | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Benefits allowed | ||||||
![]() ![]() ![]() ![]() ![]() ![]() |
unsignedInt | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
Money | |||||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Benefits used | ||||||
![]() ![]() ![]() ![]() ![]() ![]() |
unsignedInt | |||||||
![]() ![]() ![]() ![]() ![]() ![]() |
Money | |||||||
![]() |
Path | Status | Usage | ValueSet | Version | Source |
ExplanationOfBenefit.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.priority | Base | example | Process Priority Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.5 |
ExplanationOfBenefit.item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.total.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.financial.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
Id | Grade | Path(s) | Description | Expression |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
dom-3 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management |
text.`div`.exists()
|
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from ExplanationOfBenefit
Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
![]() ![]() ![]() |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
![]() ![]() ![]() |
SΣ | 1..1 | dateTime | Response creation date |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
![]() ![]() ![]() |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
![]() ![]() ![]() |
Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
![]() ![]() ![]() |
Σ | 1..* | BackboneElement | Patient insurance information |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
![]() ![]() ![]() ![]() |
Σ | 1..1 | Reference(Coverage) | Insurance information |
![]() |
Path | Status | Usage | ValueSet | Version | Source |
ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
Id | Grade | Path(s) | Description | Expression |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
dom-3 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management |
text.`div`.exists()
|
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Differential View
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | ExplanationOfBenefit | Explanation of Benefit resource | |
![]() ![]() ![]() |
S | 1..1 | code | active | cancelled | draft | entered-in-error |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Category or discipline |
![]() ![]() ![]() |
S | 1..1 | Reference(Patient) | The recipient of the products and services |
![]() ![]() ![]() |
S | 1..1 | dateTime | Response creation date |
![]() ![]() ![]() |
S | 1..1 | Reference(Organization) | Party responsible for reimbursement |
![]() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
0..* | ExplanationOfBenefit | Explanation of Benefit resource | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
0..* | Identifier | Business Identifier for the resource | |||||
![]() ![]() ![]() |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
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SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
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0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
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Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. | ||||
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SΣ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
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Σ | 0..1 | Period | Relevant time frame for the claim | ||||
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SΣ | 1..1 | dateTime | Response creation date | ||||
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0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
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SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
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Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
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0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | |||||
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0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Claim) | Reference to the related claim | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
![]() ![]() ![]() |
0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||
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0..1 | BackboneElement | Recipient of benefits payable | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
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0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
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0..1 | Reference(ServiceRequest) | Treatment Referral | |||||
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0..1 | Reference(Location) | Servicing Facility | |||||
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0..1 | Reference(Claim) | Claim reference | |||||
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0..1 | Reference(ClaimResponse) | Claim response reference | |||||
![]() ![]() ![]() |
Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
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0..1 | string | Disposition Message | |||||
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0..* | string | Preauthorization reference | |||||
![]() ![]() ![]() |
0..* | Period | Preauthorization in-effect period | |||||
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0..* | BackboneElement | Care Team members | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Order of care team | |||||
![]() ![]() ![]() ![]() |
1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Indicator of the lead practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Supporting information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Information instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
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0..1 | When it occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Data to be provided | ||||||
![]() ![]() ![]() ![]() ![]() |
boolean | |||||||
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string | |||||||
![]() ![]() ![]() ![]() ![]() |
Quantity | |||||||
![]() ![]() ![]() ![]() ![]() |
Attachment | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Resource) | |||||||
![]() ![]() ![]() ![]() |
0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Pertinent diagnosis information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Diagnosis instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Condition) | |||||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Procedure instance identifier | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | When the procedure was performed | |||||
![]() ![]() ![]() ![]() |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
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Σ | 1..* | BackboneElement | Patient insurance information | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
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Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | BackboneElement | Details of the event | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | date | When the incident occurred | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
![]() ![]() ![]() ![]() |
0..1 | Where the event occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
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0..* | BackboneElement | Product or service provided | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Item instance identifier | |||||
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0..* | positiveInt | Applicable care team members | |||||
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0..* | positiveInt | Applicable diagnoses | |||||
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0..* | positiveInt | Applicable procedures | |||||
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0..* | positiveInt | Applicable exception and supporting information | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
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0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | Date or dates of service or product delivery | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
![]() ![]() ![]() ![]() |
0..* | Reference(Encounter) | Encounters related to this billed item | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
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0..* | BackboneElement | Adjudication details | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Monetary amount | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Non-monitary value | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Additional items | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | positiveInt | Product or service provided | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | BackboneElement | Additional items | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | positiveInt | Product or service provided | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Insurer added line items | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Item sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Detail sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Subdetail sequence number | |||||
![]() ![]() ![]() ![]() |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | Date or dates of service or product delivery | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Insurer added line items | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | BackboneElement | Insurer added line items | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity(4.0.1) | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | positiveInt | Applicable note numbers | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
![]() ![]() ![]() |
0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |||||
![]() ![]() ![]() |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | Money | Financial total for the category | ||||
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0..1 | BackboneElement | Payment Details | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
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0..1 | Money | Payment adjustment for non-claim issues | |||||
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0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
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0..1 | date | Expected date of payment | |||||
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0..1 | Money | Payable amount after adjustment | |||||
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0..1 | Identifier | Business identifier for the payment | |||||
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0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
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0..1 | Attachment | Printed reference or actual form | |||||
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0..* | BackboneElement | Note concerning adjudication | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | positiveInt | Note instance identifier | |||||
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0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
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0..1 | string | Note explanatory text | |||||
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0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
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0..1 | Period | When the benefits are applicable | |||||
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0..* | BackboneElement | Balance by Benefit Category | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
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0..1 | boolean | Excluded from the plan | |||||
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0..1 | string | Short name for the benefit | |||||
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0..1 | string | Description of the benefit or services covered | |||||
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0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
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0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
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0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
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0..* | BackboneElement | Benefit Summary | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
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0..1 | Benefits allowed | ||||||
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unsignedInt | |||||||
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string | |||||||
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Money | |||||||
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0..1 | Benefits used | ||||||
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unsignedInt | |||||||
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Money | |||||||
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Path | Status | Usage | ValueSet | Version | Source |
ExplanationOfBenefit.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.priority | Base | example | Process Priority Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.5 |
ExplanationOfBenefit.item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.item.detail.subDetail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.addItem.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.total.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
ExplanationOfBenefit.benefitBalance.financial.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
Id | Grade | Path(s) | Description | Expression |
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
dom-3 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | 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 | error | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
dom-6 | best practice | ExplanationOfBenefit | A resource should have narrative for robust management |
text.`div`.exists()
|
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from ExplanationOfBenefit
Other representations of profile: CSV, Excel, Schematron