R4 Draft for Comment
FinancialThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner, RelatedPerson |
StructureDefinition for explanationofbenefit
{
"resourceType": "StructureDefinition",
"id": "ExplanationOfBenefit",
"meta": {
"lastUpdated": "2017-12-20T15:52:34.818+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit",
"name": "ExplanationOfBenefit",
"status": "draft",
"date": "2017-12-20T15:52:34+11:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"fhirVersion": "3.2.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "v2",
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "ExplanationOfBenefit",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "ExplanationOfBenefit",
"path": "ExplanationOfBenefit",
"short": "Explanation of Benefit resource",
"definition": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"alias": [
"EOB"
],
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "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",
"expression": "contained.all(('#'+id in %resource.descendants().reference) or descendants().where(reference = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::reference[@value='#'])]))",
"source": "DomainResource"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.other"
}
]
},
{
"id": "ExplanationOfBenefit.id",
"path": "ExplanationOfBenefit.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "ExplanationOfBenefit.meta",
"path": "ExplanationOfBenefit.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "ExplanationOfBenefit.implicitRules",
"path": "ExplanationOfBenefit.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "ExplanationOfBenefit.language",
"path": "ExplanationOfBenefit.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ExplanationOfBenefit.text",
"path": "ExplanationOfBenefit.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "ExplanationOfBenefit.contained",
"path": "ExplanationOfBenefit.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.extension",
"path": "ExplanationOfBenefit.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.modifierExtension",
"path": "ExplanationOfBenefit.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.identifier",
"path": "ExplanationOfBenefit.identifier",
"short": "Business Identifier",
"definition": "The EOB Business Identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ExplanationOfBenefit.status",
"path": "ExplanationOfBenefit.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ExplanationOfBenefitStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ExplanationOfBenefit.type",
"path": "ExplanationOfBenefit.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "extensible",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.code"
},
{
"identity": "w5",
"map": "FiveWs.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "ExplanationOfBenefit.subType",
"path": "ExplanationOfBenefit.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "ExplanationOfBenefit.patient",
"path": "ExplanationOfBenefit.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "ExplanationOfBenefit.billablePeriod",
"path": "ExplanationOfBenefit.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ExplanationOfBenefit.created",
"path": "ExplanationOfBenefit.created",
"short": "Creation date",
"definition": "The date when the EOB was created.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence[x]"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ExplanationOfBenefit.enterer",
"path": "ExplanationOfBenefit.enterer",
"short": "Author",
"definition": "The person who created the explanation of benefit.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.agent"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ExplanationOfBenefit.insurer",
"path": "ExplanationOfBenefit.insurer",
"short": "Insurer responsible for the EOB",
"definition": "The insurer which is responsible for the explanation of benefit.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.agent"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ExplanationOfBenefit.provider",
"path": "ExplanationOfBenefit.provider",
"short": "Responsible provider for the claim",
"definition": "The provider which is responsible for the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ExplanationOfBenefit.organization",
"path": "ExplanationOfBenefit.organization",
"short": "Responsible organization for the claim",
"definition": "The provider which is responsible for the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ExplanationOfBenefit.referral",
"path": "ExplanationOfBenefit.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ServiceRequest"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.cause"
},
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"id": "ExplanationOfBenefit.facility",
"path": "ExplanationOfBenefit.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.location"
},
{
"identity": "w5",
"map": "FiveWs.where[x]"
},
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "ExplanationOfBenefit.claim",
"path": "ExplanationOfBenefit.claim",
"short": "Claim reference",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ExplanationOfBenefit.claimResponse",
"path": "ExplanationOfBenefit.claimResponse",
"short": "Claim response reference",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
},
{
"id": "ExplanationOfBenefit.outcome",
"path": "ExplanationOfBenefit.outcome",
"short": "complete | error | partial",
"definition": "Processing outcome errror, partial or complete processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
}
],
"strength": "required",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "ExplanationOfBenefit.disposition",
"path": "ExplanationOfBenefit.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"comment": "Do we need a disposition code?",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "ExplanationOfBenefit.related",
"short": "Related Claims which may be revelant to processing this claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.related.id",
"path": "ExplanationOfBenefit.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.related.extension",
"path": "ExplanationOfBenefit.related.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.related.modifierExtension",
"path": "ExplanationOfBenefit.related.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.related.claim",
"path": "ExplanationOfBenefit.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
]
},
{
"id": "ExplanationOfBenefit.related.relationship",
"path": "ExplanationOfBenefit.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "ExplanationOfBenefit.related.reference",
"path": "ExplanationOfBenefit.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ExplanationOfBenefit.prescription",
"path": "ExplanationOfBenefit.prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
]
},
{
"id": "ExplanationOfBenefit.originalPrescription",
"path": "ExplanationOfBenefit.originalPrescription",
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}
]
},
{
"id": "ExplanationOfBenefit.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "ExplanationOfBenefit.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.payee.id",
"path": "ExplanationOfBenefit.payee.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.payee.extension",
"path": "ExplanationOfBenefit.payee.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.payee.modifierExtension",
"path": "ExplanationOfBenefit.payee.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.payee.type",
"path": "ExplanationOfBenefit.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "ExplanationOfBenefit.payee.resource",
"path": "ExplanationOfBenefit.payee.resource",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeResourceType"
}
],
"strength": "extensible",
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/resource-type-link"
}
}
},
{
"id": "ExplanationOfBenefit.payee.party",
"path": "ExplanationOfBenefit.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
]
},
{
"id": "ExplanationOfBenefit.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
}
],
"path": "ExplanationOfBenefit.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.information.id",
"path": "ExplanationOfBenefit.information.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.information.extension",
"path": "ExplanationOfBenefit.information.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.information.modifierExtension",
"path": "ExplanationOfBenefit.information.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.information.sequence",
"path": "ExplanationOfBenefit.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.information.category",
"path": "ExplanationOfBenefit.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"id": "ExplanationOfBenefit.information.code",
"path": "ExplanationOfBenefit.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"id": "ExplanationOfBenefit.information.timing[x]",
"path": "ExplanationOfBenefit.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.information.value[x]",
"path": "ExplanationOfBenefit.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
]
},
{
"id": "ExplanationOfBenefit.information.reason",
"path": "ExplanationOfBenefit.information.reason",
"short": "Reason associated with the information",
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"id": "ExplanationOfBenefit.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "ExplanationOfBenefit.careTeam",
"short": "Care Team members",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible might not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.id",
"path": "ExplanationOfBenefit.careTeam.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.extension",
"path": "ExplanationOfBenefit.careTeam.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.modifierExtension",
"path": "ExplanationOfBenefit.careTeam.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.sequence",
"path": "ExplanationOfBenefit.careTeam.sequence",
"short": "Number to covey order of careteam",
"definition": "Sequence of careteam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careteam members.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.provider",
"path": "ExplanationOfBenefit.careTeam.provider",
"short": "Member of the Care Team",
"definition": "The members of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.actor"
},
{
"identity": "w5",
"map": "who.actor"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.responsible",
"path": "ExplanationOfBenefit.careTeam.responsible",
"short": "Billing practitioner",
"definition": "The practitioner who is billing and responsible for the claimed services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.role",
"path": "ExplanationOfBenefit.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"id": "ExplanationOfBenefit.careTeam.qualification",
"path": "ExplanationOfBenefit.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "ExplanationOfBenefit.diagnosis",
"short": "List of Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.id",
"path": "ExplanationOfBenefit.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.extension",
"path": "ExplanationOfBenefit.diagnosis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.modifierExtension",
"path": "ExplanationOfBenefit.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.sequence",
"path": "ExplanationOfBenefit.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis.type",
"path": "ExplanationOfBenefit.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis.packageCode",
"path": "ExplanationOfBenefit.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "Required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"id": "ExplanationOfBenefit.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "ExplanationOfBenefit.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.id",
"path": "ExplanationOfBenefit.procedure.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.extension",
"path": "ExplanationOfBenefit.procedure.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.modifierExtension",
"path": "ExplanationOfBenefit.procedure.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.sequence",
"path": "ExplanationOfBenefit.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.date",
"path": "ExplanationOfBenefit.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.procedure[x]",
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"id": "ExplanationOfBenefit.precedence",
"path": "ExplanationOfBenefit.precedence",
"short": "Precedence (primary, secondary, etc.)",
"definition": "Precedence (primary, secondary, etc.).",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "ExplanationOfBenefit.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"mapping": [
{
"identity": "v2",
"map": "Coverage"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.id",
"path": "ExplanationOfBenefit.insurance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.extension",
"path": "ExplanationOfBenefit.insurance.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.modifierExtension",
"path": "ExplanationOfBenefit.insurance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.coverage",
"path": "ExplanationOfBenefit.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.preAuthRef",
"path": "ExplanationOfBenefit.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "ExplanationOfBenefit.accident",
"short": "Details of an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.accident.id",
"path": "ExplanationOfBenefit.accident.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.accident.extension",
"path": "ExplanationOfBenefit.accident.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.accident.modifierExtension",
"path": "ExplanationOfBenefit.accident.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.accident.date",
"path": "ExplanationOfBenefit.accident.date",
"short": "When the accident occurred",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ExplanationOfBenefit.accident.type",
"path": "ExplanationOfBenefit.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "extensible",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"id": "ExplanationOfBenefit.accident.location[x]",
"path": "ExplanationOfBenefit.accident.location[x]",
"short": "Accident Place",
"definition": "Where the accident occurred.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
]
},
{
"id": "ExplanationOfBenefit.employmentImpacted",
"path": "ExplanationOfBenefit.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.hospitalization",
"path": "ExplanationOfBenefit.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "ExplanationOfBenefit.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.item.id",
"path": "ExplanationOfBenefit.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.extension",
"path": "ExplanationOfBenefit.item.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.modifierExtension",
"path": "ExplanationOfBenefit.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.item.sequence",
"path": "ExplanationOfBenefit.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.careTeamSequence",
"path": "ExplanationOfBenefit.item.careTeamSequence",
"short": "Applicable careteam members",
"definition": "Careteam applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.diagnosisSequence",
"path": "ExplanationOfBenefit.item.diagnosisSequence",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.procedureSequence",
"path": "ExplanationOfBenefit.item.procedureSequence",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.informationSequence",
"path": "ExplanationOfBenefit.item.informationSequence",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.revenue",
"path": "ExplanationOfBenefit.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.category",
"path": "ExplanationOfBenefit.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.service",
"path": "ExplanationOfBenefit.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.modifier",
"path": "ExplanationOfBenefit.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.programCode",
"path": "ExplanationOfBenefit.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.serviced[x]",
"path": "ExplanationOfBenefit.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ExplanationOfBenefit.item.location[x]",
"path": "ExplanationOfBenefit.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
},
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "ExplanationOfBenefit.item.quantity",
"path": "ExplanationOfBenefit.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.unitPrice",
"path": "ExplanationOfBenefit.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.factor",
"path": "ExplanationOfBenefit.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.net",
"path": "ExplanationOfBenefit.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.udi",
"path": "ExplanationOfBenefit.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.bodySite",
"path": "ExplanationOfBenefit.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"id": "ExplanationOfBenefit.item.subSite",
"path": "ExplanationOfBenefit.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "ExplanationOfBenefit.item.encounter",
"path": "ExplanationOfBenefit.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
]
},
{
"id": "ExplanationOfBenefit.item.noteNumber",
"path": "ExplanationOfBenefit.item.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
}
],
"path": "ExplanationOfBenefit.item.adjudication",
"short": "Adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.id",
"path": "ExplanationOfBenefit.item.adjudication.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.extension",
"path": "ExplanationOfBenefit.item.adjudication.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"path": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.category",
"path": "ExplanationOfBenefit.item.adjudication.category",
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
}
],
"strength": "example",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
}
},
{
"id": "ExplanationOfBenefit.item.adjudication.reason",
"path": "ExplanationOfBenefit.item.adjudication.reason",
"short": "Explanation of Adjudication outcome",
"definition": "Adjudication reason such as limit reached.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
}
],
"strength": "example",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
}
},
{
"id": "ExplanationOfBenefit.item.adjudication.amount",
"path": "ExplanationOfBenefit.item.adjudication.amount",
"short": "Monetary amount",
"definition": "Monitory amount associated with the code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.value",
"path": "ExplanationOfBenefit.item.adjudication.value",
"short": "Non-monitory value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "ExplanationOfBenefit.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.id",
"path": "ExplanationOfBenefit.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.extension",
"path": "ExplanationOfBenefit.item.detail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.modifierExtension",
"path": "ExplanationOfBenefit.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.sequence",
"path": "ExplanationOfBenefit.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.revenue",
"path": "ExplanationOfBenefit.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.category",
"path": "ExplanationOfBenefit.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.service",
"path": "ExplanationOfBenefit.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.modifier",
"path": "ExplanationOfBenefit.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.programCode",
"path": "ExplanationOfBenefit.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.quantity",
"path": "ExplanationOfBenefit.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.unitPrice",
"path": "ExplanationOfBenefit.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.factor",
"path": "ExplanationOfBenefit.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.net",
"path": "ExplanationOfBenefit.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.udi",
"path": "ExplanationOfBenefit.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.noteNumber",
"path": "ExplanationOfBenefit.item.detail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.adjudication",
"path": "ExplanationOfBenefit.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "ExplanationOfBenefit.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.id",
"path": "ExplanationOfBenefit.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.extension",
"path": "ExplanationOfBenefit.item.detail.subDetail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"path": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.category",
"path": "ExplanationOfBenefit.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.service",
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.factor",
"path": "ExplanationOfBenefit.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.net",
"path": "ExplanationOfBenefit.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.udi",
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"short": "Language if different from the resource",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.addItem",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
}
],
"path": "ExplanationOfBenefit.addItem",
"short": "Insurer added line items",
"definition": "The first tier service adjudications for payor added services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.id",
"path": "ExplanationOfBenefit.addItem.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.extension",
"path": "ExplanationOfBenefit.addItem.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.modifierExtension",
"path": "ExplanationOfBenefit.addItem.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.itemSequence",
"path": "ExplanationOfBenefit.addItem.itemSequence",
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.detailSequence",
"path": "ExplanationOfBenefit.addItem.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.subDetailSequence",
"path": "ExplanationOfBenefit.addItem.subDetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.service",
"path": "ExplanationOfBenefit.addItem.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.addItem.modifier",
"path": "ExplanationOfBenefit.addItem.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.addItem.fee",
"path": "ExplanationOfBenefit.addItem.fee",
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.noteNumber",
"path": "ExplanationOfBenefit.addItem.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.adjudication",
"path": "ExplanationOfBenefit.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.totalCost",
"path": "ExplanationOfBenefit.totalCost",
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.unallocDeductable",
"path": "ExplanationOfBenefit.unallocDeductable",
"short": "Unallocated deductable",
"definition": "The amount of deductable applied which was not allocated to any particular service line.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.totalBenefit",
"path": "ExplanationOfBenefit.totalBenefit",
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
}
],
"path": "ExplanationOfBenefit.payment",
"short": "Payment (if paid)",
"definition": "Payment details for the claim if the claim has been paid.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.payment.id",
"path": "ExplanationOfBenefit.payment.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.payment.extension",
"path": "ExplanationOfBenefit.payment.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.payment.modifierExtension",
"path": "ExplanationOfBenefit.payment.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.payment.type",
"path": "ExplanationOfBenefit.payment.type",
"short": "Partial or Complete",
"definition": "Whether this represents partial or complete payment of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
}
],
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
}
},
{
"id": "ExplanationOfBenefit.payment.adjustment",
"path": "ExplanationOfBenefit.payment.adjustment",
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment.adjustmentReason",
"path": "ExplanationOfBenefit.payment.adjustmentReason",
"short": "Explanation for the non-claim adjustment",
"definition": "Reason for the payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
}
],
"strength": "example",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
}
},
{
"id": "ExplanationOfBenefit.payment.date",
"path": "ExplanationOfBenefit.payment.date",
"short": "Expected date of Payment",
"definition": "Estimated payment date.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ExplanationOfBenefit.payment.amount",
"path": "ExplanationOfBenefit.payment.amount",
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment.identifier",
"path": "ExplanationOfBenefit.payment.identifier",
"short": "Identifier of the payment instrument",
"definition": "Payment identifer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ExplanationOfBenefit.form",
"path": "ExplanationOfBenefit.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
}
},
{
"id": "ExplanationOfBenefit.processNote",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
}
],
"path": "ExplanationOfBenefit.processNote",
"short": "Processing notes",
"definition": "Note text.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.id",
"path": "ExplanationOfBenefit.processNote.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.extension",
"path": "ExplanationOfBenefit.processNote.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.modifierExtension",
"path": "ExplanationOfBenefit.processNote.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.number",
"path": "ExplanationOfBenefit.processNote.number",
"short": "Sequence number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.type",
"path": "ExplanationOfBenefit.processNote.type",
"short": "display | print | printoper",
"definition": "The note purpose: Print/Display.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
}
},
{
"id": "ExplanationOfBenefit.processNote.text",
"path": "ExplanationOfBenefit.processNote.text",
"short": "Note explanitory text",
"definition": "The note text.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.language",
"path": "ExplanationOfBenefit.processNote.language",
"short": "Language if different from the resource",
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
}
],
"path": "ExplanationOfBenefit.benefitBalance",
"short": "Balance by Benefit Category",
"definition": "Balance by Benefit Category.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.id",
"path": "ExplanationOfBenefit.benefitBalance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.extension",
"path": "ExplanationOfBenefit.benefitBalance.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"path": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.category",
"path": "ExplanationOfBenefit.benefitBalance.category",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.subCategory",
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.excluded",
"path": "ExplanationOfBenefit.benefitBalance.excluded",
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.name",
"path": "ExplanationOfBenefit.benefitBalance.name",
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.description",
"path": "ExplanationOfBenefit.benefitBalance.description",
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.network",
"path": "ExplanationOfBenefit.benefitBalance.network",
"short": "In or out of network",
"definition": "Network designation.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
}
],
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.unit",
"path": "ExplanationOfBenefit.benefitBalance.unit",
"short": "Individual or family",
"definition": "Unit designation: individual or family.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
}
],
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.term",
"path": "ExplanationOfBenefit.benefitBalance.term",
"short": "Annual or lifetime",
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
}
],
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
}
],
"path": "ExplanationOfBenefit.benefitBalance.financial",
"short": "Benefit Summary",
"definition": "Benefits Used to date.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.id",
"path": "ExplanationOfBenefit.benefitBalance.financial.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.extension",
"path": "ExplanationOfBenefit.benefitBalance.financial.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"path": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.type",
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"short": "Deductable, visits, benefit amount",
"definition": "Deductable, visits, benefit amount.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
}
],
"strength": "example",
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"short": "Benefits allowed",
"definition": "Benefits allowed.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "string"
},
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"short": "Benefits used",
"definition": "Benefits used.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "Money"
}
]
}
]
},
"differential": {
"element": [
{
"id": "ExplanationOfBenefit",
"path": "ExplanationOfBenefit",
"short": "Explanation of Benefit resource",
"definition": "This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.",
"alias": [
"EOB"
],
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.other"
}
]
},
{
"id": "ExplanationOfBenefit.identifier",
"path": "ExplanationOfBenefit.identifier",
"short": "Business Identifier",
"definition": "The EOB Business Identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ExplanationOfBenefit.status",
"path": "ExplanationOfBenefit.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ExplanationOfBenefitStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/explanationofbenefit-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ExplanationOfBenefit.type",
"path": "ExplanationOfBenefit.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "extensible",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.code"
},
{
"identity": "w5",
"map": "FiveWs.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "ExplanationOfBenefit.subType",
"path": "ExplanationOfBenefit.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "A more granulat claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "ExplanationOfBenefit.patient",
"path": "ExplanationOfBenefit.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "ExplanationOfBenefit.billablePeriod",
"path": "ExplanationOfBenefit.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ExplanationOfBenefit.created",
"path": "ExplanationOfBenefit.created",
"short": "Creation date",
"definition": "The date when the EOB was created.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence[x]"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ExplanationOfBenefit.enterer",
"path": "ExplanationOfBenefit.enterer",
"short": "Author",
"definition": "The person who created the explanation of benefit.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.agent"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ExplanationOfBenefit.insurer",
"path": "ExplanationOfBenefit.insurer",
"short": "Insurer responsible for the EOB",
"definition": "The insurer which is responsible for the explanation of benefit.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.agent"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ExplanationOfBenefit.provider",
"path": "ExplanationOfBenefit.provider",
"short": "Responsible provider for the claim",
"definition": "The provider which is responsible for the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ExplanationOfBenefit.organization",
"path": "ExplanationOfBenefit.organization",
"short": "Responsible organization for the claim",
"definition": "The provider which is responsible for the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ExplanationOfBenefit.referral",
"path": "ExplanationOfBenefit.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ServiceRequest"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.cause"
},
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"id": "ExplanationOfBenefit.facility",
"path": "ExplanationOfBenefit.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.location"
},
{
"identity": "w5",
"map": "FiveWs.where[x]"
},
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "ExplanationOfBenefit.claim",
"path": "ExplanationOfBenefit.claim",
"short": "Claim reference",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ExplanationOfBenefit.claimResponse",
"path": "ExplanationOfBenefit.claimResponse",
"short": "Claim response reference",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
},
{
"id": "ExplanationOfBenefit.outcome",
"path": "ExplanationOfBenefit.outcome",
"short": "complete | error | partial",
"definition": "Processing outcome errror, partial or complete processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
}
],
"strength": "required",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "ExplanationOfBenefit.disposition",
"path": "ExplanationOfBenefit.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"comment": "Do we need a disposition code?",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "ExplanationOfBenefit.related",
"short": "Related Claims which may be revelant to processing this claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.related.claim",
"path": "ExplanationOfBenefit.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
]
},
{
"id": "ExplanationOfBenefit.related.relationship",
"path": "ExplanationOfBenefit.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "ExplanationOfBenefit.related.reference",
"path": "ExplanationOfBenefit.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ExplanationOfBenefit.prescription",
"path": "ExplanationOfBenefit.prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
]
},
{
"id": "ExplanationOfBenefit.originalPrescription",
"path": "ExplanationOfBenefit.originalPrescription",
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}
]
},
{
"id": "ExplanationOfBenefit.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "ExplanationOfBenefit.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.payee.type",
"path": "ExplanationOfBenefit.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "ExplanationOfBenefit.payee.resource",
"path": "ExplanationOfBenefit.payee.resource",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeResourceType"
}
],
"strength": "extensible",
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/resource-type-link"
}
}
},
{
"id": "ExplanationOfBenefit.payee.party",
"path": "ExplanationOfBenefit.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
]
},
{
"id": "ExplanationOfBenefit.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
}
],
"path": "ExplanationOfBenefit.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.information.sequence",
"path": "ExplanationOfBenefit.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.information.category",
"path": "ExplanationOfBenefit.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"id": "ExplanationOfBenefit.information.code",
"path": "ExplanationOfBenefit.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"id": "ExplanationOfBenefit.information.timing[x]",
"path": "ExplanationOfBenefit.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.information.value[x]",
"path": "ExplanationOfBenefit.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
]
},
{
"id": "ExplanationOfBenefit.information.reason",
"path": "ExplanationOfBenefit.information.reason",
"short": "Reason associated with the information",
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"id": "ExplanationOfBenefit.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "ExplanationOfBenefit.careTeam",
"short": "Care Team members",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible might not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.sequence",
"path": "ExplanationOfBenefit.careTeam.sequence",
"short": "Number to covey order of careteam",
"definition": "Sequence of careteam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careteam members.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.provider",
"path": "ExplanationOfBenefit.careTeam.provider",
"short": "Member of the Care Team",
"definition": "The members of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.actor"
},
{
"identity": "w5",
"map": "who.actor"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.responsible",
"path": "ExplanationOfBenefit.careTeam.responsible",
"short": "Billing practitioner",
"definition": "The practitioner who is billing and responsible for the claimed services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ExplanationOfBenefit.careTeam.role",
"path": "ExplanationOfBenefit.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"id": "ExplanationOfBenefit.careTeam.qualification",
"path": "ExplanationOfBenefit.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "ExplanationOfBenefit.diagnosis",
"short": "List of Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.sequence",
"path": "ExplanationOfBenefit.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"path": "ExplanationOfBenefit.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis.type",
"path": "ExplanationOfBenefit.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"id": "ExplanationOfBenefit.diagnosis.packageCode",
"path": "ExplanationOfBenefit.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "Required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"id": "ExplanationOfBenefit.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "ExplanationOfBenefit.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.sequence",
"path": "ExplanationOfBenefit.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.date",
"path": "ExplanationOfBenefit.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "ExplanationOfBenefit.procedure.procedure[x]",
"path": "ExplanationOfBenefit.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"id": "ExplanationOfBenefit.precedence",
"path": "ExplanationOfBenefit.precedence",
"short": "Precedence (primary, secondary, etc.)",
"definition": "Precedence (primary, secondary, etc.).",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "ExplanationOfBenefit.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "v2",
"map": "Coverage"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.coverage",
"path": "ExplanationOfBenefit.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "ExplanationOfBenefit.insurance.preAuthRef",
"path": "ExplanationOfBenefit.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "ExplanationOfBenefit.accident",
"short": "Details of an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.accident.date",
"path": "ExplanationOfBenefit.accident.date",
"short": "When the accident occurred",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ExplanationOfBenefit.accident.type",
"path": "ExplanationOfBenefit.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "extensible",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"id": "ExplanationOfBenefit.accident.location[x]",
"path": "ExplanationOfBenefit.accident.location[x]",
"short": "Accident Place",
"definition": "Where the accident occurred.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
]
},
{
"id": "ExplanationOfBenefit.employmentImpacted",
"path": "ExplanationOfBenefit.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.hospitalization",
"path": "ExplanationOfBenefit.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "ExplanationOfBenefit.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "ExplanationOfBenefit.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.item.sequence",
"path": "ExplanationOfBenefit.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.careTeamSequence",
"path": "ExplanationOfBenefit.item.careTeamSequence",
"short": "Applicable careteam members",
"definition": "Careteam applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.diagnosisSequence",
"path": "ExplanationOfBenefit.item.diagnosisSequence",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.procedureSequence",
"path": "ExplanationOfBenefit.item.procedureSequence",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.informationSequence",
"path": "ExplanationOfBenefit.item.informationSequence",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.revenue",
"path": "ExplanationOfBenefit.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.category",
"path": "ExplanationOfBenefit.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.service",
"path": "ExplanationOfBenefit.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.modifier",
"path": "ExplanationOfBenefit.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.programCode",
"path": "ExplanationOfBenefit.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.serviced[x]",
"path": "ExplanationOfBenefit.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ExplanationOfBenefit.item.location[x]",
"path": "ExplanationOfBenefit.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Place where the service is rendered",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
},
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "ExplanationOfBenefit.item.quantity",
"path": "ExplanationOfBenefit.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.unitPrice",
"path": "ExplanationOfBenefit.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.factor",
"path": "ExplanationOfBenefit.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.net",
"path": "ExplanationOfBenefit.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.udi",
"path": "ExplanationOfBenefit.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.bodySite",
"path": "ExplanationOfBenefit.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"id": "ExplanationOfBenefit.item.subSite",
"path": "ExplanationOfBenefit.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "ExplanationOfBenefit.item.encounter",
"path": "ExplanationOfBenefit.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
]
},
{
"id": "ExplanationOfBenefit.item.noteNumber",
"path": "ExplanationOfBenefit.item.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
}
],
"path": "ExplanationOfBenefit.item.adjudication",
"short": "Adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.category",
"path": "ExplanationOfBenefit.item.adjudication.category",
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"definition": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
}
],
"strength": "example",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
}
},
{
"id": "ExplanationOfBenefit.item.adjudication.reason",
"path": "ExplanationOfBenefit.item.adjudication.reason",
"short": "Explanation of Adjudication outcome",
"definition": "Adjudication reason such as limit reached.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
}
],
"strength": "example",
"description": "Adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
}
},
{
"id": "ExplanationOfBenefit.item.adjudication.amount",
"path": "ExplanationOfBenefit.item.adjudication.amount",
"short": "Monetary amount",
"definition": "Monitory amount associated with the code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.adjudication.value",
"path": "ExplanationOfBenefit.item.adjudication.value",
"short": "Non-monitory value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "ExplanationOfBenefit.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.sequence",
"path": "ExplanationOfBenefit.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.revenue",
"path": "ExplanationOfBenefit.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.category",
"path": "ExplanationOfBenefit.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.service",
"path": "ExplanationOfBenefit.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.modifier",
"path": "ExplanationOfBenefit.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.programCode",
"path": "ExplanationOfBenefit.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.quantity",
"path": "ExplanationOfBenefit.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.unitPrice",
"path": "ExplanationOfBenefit.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.factor",
"path": "ExplanationOfBenefit.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.net",
"path": "ExplanationOfBenefit.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.udi",
"path": "ExplanationOfBenefit.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.noteNumber",
"path": "ExplanationOfBenefit.item.detail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.adjudication",
"path": "ExplanationOfBenefit.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "ExplanationOfBenefit.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"path": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"path": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.category",
"path": "ExplanationOfBenefit.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.service",
"path": "ExplanationOfBenefit.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"path": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"path": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"path": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"path": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.factor",
"path": "ExplanationOfBenefit.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.net",
"path": "ExplanationOfBenefit.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.udi",
"path": "ExplanationOfBenefit.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"path": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"path": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"short": "Language if different from the resource",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.addItem",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
}
],
"path": "ExplanationOfBenefit.addItem",
"short": "Insurer added line items",
"definition": "The first tier service adjudications for payor added services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.itemSequence",
"path": "ExplanationOfBenefit.addItem.itemSequence",
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.detailSequence",
"path": "ExplanationOfBenefit.addItem.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.subDetailSequence",
"path": "ExplanationOfBenefit.addItem.subDetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.service",
"path": "ExplanationOfBenefit.addItem.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ExplanationOfBenefit.addItem.modifier",
"path": "ExplanationOfBenefit.addItem.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "ExplanationOfBenefit.addItem.fee",
"path": "ExplanationOfBenefit.addItem.fee",
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.noteNumber",
"path": "ExplanationOfBenefit.addItem.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.addItem.adjudication",
"path": "ExplanationOfBenefit.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ExplanationOfBenefit.item.adjudication"
},
{
"id": "ExplanationOfBenefit.totalCost",
"path": "ExplanationOfBenefit.totalCost",
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.unallocDeductable",
"path": "ExplanationOfBenefit.unallocDeductable",
"short": "Unallocated deductable",
"definition": "The amount of deductable applied which was not allocated to any particular service line.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.totalBenefit",
"path": "ExplanationOfBenefit.totalBenefit",
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
}
],
"path": "ExplanationOfBenefit.payment",
"short": "Payment (if paid)",
"definition": "Payment details for the claim if the claim has been paid.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.payment.type",
"path": "ExplanationOfBenefit.payment.type",
"short": "Partial or Complete",
"definition": "Whether this represents partial or complete payment of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
}
],
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
}
},
{
"id": "ExplanationOfBenefit.payment.adjustment",
"path": "ExplanationOfBenefit.payment.adjustment",
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment.adjustmentReason",
"path": "ExplanationOfBenefit.payment.adjustmentReason",
"short": "Explanation for the non-claim adjustment",
"definition": "Reason for the payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
}
],
"strength": "example",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
}
},
{
"id": "ExplanationOfBenefit.payment.date",
"path": "ExplanationOfBenefit.payment.date",
"short": "Expected date of Payment",
"definition": "Estimated payment date.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ExplanationOfBenefit.payment.amount",
"path": "ExplanationOfBenefit.payment.amount",
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.payment.identifier",
"path": "ExplanationOfBenefit.payment.identifier",
"short": "Identifier of the payment instrument",
"definition": "Payment identifer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ExplanationOfBenefit.form",
"path": "ExplanationOfBenefit.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
}
},
{
"id": "ExplanationOfBenefit.processNote",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
}
],
"path": "ExplanationOfBenefit.processNote",
"short": "Processing notes",
"definition": "Note text.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.number",
"path": "ExplanationOfBenefit.processNote.number",
"short": "Sequence number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.type",
"path": "ExplanationOfBenefit.processNote.type",
"short": "display | print | printoper",
"definition": "The note purpose: Print/Display.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
}
},
{
"id": "ExplanationOfBenefit.processNote.text",
"path": "ExplanationOfBenefit.processNote.text",
"short": "Note explanitory text",
"definition": "The note text.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.processNote.language",
"path": "ExplanationOfBenefit.processNote.language",
"short": "Language if different from the resource",
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BenefitBalance"
}
],
"path": "ExplanationOfBenefit.benefitBalance",
"short": "Balance by Benefit Category",
"definition": "Balance by Benefit Category.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.category",
"path": "ExplanationOfBenefit.benefitBalance.category",
"short": "Type of services covered",
"definition": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
}
],
"strength": "example",
"description": "Benefit categories such as: oral, medical, vision etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-category"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.subCategory",
"path": "ExplanationOfBenefit.benefitBalance.subCategory",
"short": "Detailed services covered within the type",
"definition": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.excluded",
"path": "ExplanationOfBenefit.benefitBalance.excluded",
"short": "Excluded from the plan",
"definition": "True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.name",
"path": "ExplanationOfBenefit.benefitBalance.name",
"short": "Short name for the benefit",
"definition": "A short name or tag for the benefit, for example MED01, or DENT2.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.description",
"path": "ExplanationOfBenefit.benefitBalance.description",
"short": "Description of the benefit or services covered",
"definition": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.network",
"path": "ExplanationOfBenefit.benefitBalance.network",
"short": "In or out of network",
"definition": "Network designation.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitNetwork"
}
],
"strength": "example",
"description": "Code to classify in or out of network services",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-network"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.unit",
"path": "ExplanationOfBenefit.benefitBalance.unit",
"short": "Individual or family",
"definition": "Unit designation: individual or family.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitUnit"
}
],
"strength": "example",
"description": "Unit covered/serviced - individual or family",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-unit"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.term",
"path": "ExplanationOfBenefit.benefitBalance.term",
"short": "Annual or lifetime",
"definition": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitTerm"
}
],
"strength": "example",
"description": "Coverage unit - annual, lifetime",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-term"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Benefit"
}
],
"path": "ExplanationOfBenefit.benefitBalance.financial",
"short": "Benefit Summary",
"definition": "Benefits Used to date.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.type",
"path": "ExplanationOfBenefit.benefitBalance.financial.type",
"short": "Deductable, visits, benefit amount",
"definition": "Deductable, visits, benefit amount.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitType"
}
],
"strength": "example",
"description": "Deductable, visits, co-pay, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-type"
}
}
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"path": "ExplanationOfBenefit.benefitBalance.financial.allowed[x]",
"short": "Benefits allowed",
"definition": "Benefits allowed.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "string"
},
{
"code": "Money"
}
]
},
{
"id": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"path": "ExplanationOfBenefit.benefitBalance.financial.used[x]",
"short": "Benefits used",
"definition": "Benefits used.",
"min": 0,
"max": "1",
"type": [
{
"code": "unsignedInt"
},
{
"code": "Money"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:57+1100. QA Page
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