ExplanationOfBenefit - FHIR v5.0.0-ballot

This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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

13.10.10 Resource ExplanationOfBenefit - R4/R5 Conversions

Financial Management

Work Group

Maturity Level: N/A

Standards Status: Informative

Security Category: Patient

Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

R4 : R5 Conversion maps for ExplanationOfBenefit.

Functional status for this map: 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). (see documentation)

13.10.10.1 R4 to R5

map "http://hl7.org/fhir/StructureMap/ExplanationOfBenefit3to4" = "R3 to R4 Conversions for ExplanationOfBenefit"

uses "http://hl7.org/fhir/3.0/StructureDefinition/ExplanationOfBenefit" alias ExplanationOfBenefitR3 as source
uses "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit" alias ExplanationOfBenefit as target

imports "http://hl7.org/fhir/StructureMap/*3to4"

group ExplanationOfBenefit(source src : ExplanationOfBenefitR3, target tgt : ExplanationOfBenefit) extends DomainResource <<type+>> {
  src.identifier -> tgt.identifier;
  src.status -> tgt.status;
  src.type -> tgt.type;
  src.subType -> tgt.subType;
  src.use -> tgt.use;
  src.patient -> tgt.patient;
  src.billablePeriod -> tgt.billablePeriod;
  src.created -> tgt.created;
  src.enterer -> tgt.enterer;
  src.insurer -> tgt.insurer;
  src.provider -> tgt.provider;
  src.referral -> tgt.referral;
  src.facility -> tgt.facility;
  src.claim -> tgt.claim;
  src.claimResponse -> tgt.claimResponse;
  src.outcome as vs then {
    vs.coding as c where code in ('complete' | 'error' | 'partial') then {
      c.code -> tgt.outcome;
    };
  };
  src.disposition -> tgt.disposition;
  src.related as s -> tgt.related as t then ExplanationOfBenefitRelated(s, t);
  src.prescription -> tgt.prescription;
  src.originalPrescription -> tgt.originalPrescription;
  src.payee as s -> tgt.payee as t then ExplanationOfBenefitPayee(s, t);
  src.information as s -> tgt.supportingInfo as t then ExplanationOfBenefitInformation(s, t);
  src.careTeam as s -> tgt.careTeam as t then ExplanationOfBenefitCareTeam(s, t);
  src.diagnosis as s -> tgt.diagnosis as t then ExplanationOfBenefitDiagnosis(s, t);
  src.procedure as s -> tgt.procedure as t then ExplanationOfBenefitProcedure(s, t);
  src.precedence -> tgt.precedence;
  src.insurance as s -> tgt.insurance as t then ExplanationOfBenefitInsurance(s, t);
  src.accident as s -> tgt.accident as t then ExplanationOfBenefitAccident(s, t);
  src.item as s -> tgt.item as t then ExplanationOfBenefitItem(s, t);
  src.addItem as s -> tgt.addItem as t then ExplanationOfBenefitAddItem(s, t);
  src.totalCost as s -> tgt.total as t then ExplanationOfBenefitTotalCost(s, t);
  src.totalBenefit as s -> tgt.total as t then ExplanationOfBenefitTotalBenefit(s, t);
  src.payment as s -> tgt.payment as t then ExplanationOfBenefitPayment(s, t);
  src.form -> tgt.form;
  src.processNote as s -> tgt.processNote as t then ExplanationOfBenefitProcessNote(s, t);
  src.benefitBalance as s -> tgt.benefitBalance as t then ExplanationOfBenefitBenefitBalance(s, t);
}

group ExplanationOfBenefitRelated(source src, target tgt) extends BackboneElement {
  src.claim -> tgt.claim;
  src.relationship -> tgt.relationship;
  src.reference -> tgt.reference;
}

group ExplanationOfBenefitPayee(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.party -> tgt.party;
}

group ExplanationOfBenefitInformation(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.category -> tgt.category;
  src.code -> tgt.code;
  src.timing -> tgt.timing;
  src.value -> tgt.value;
  src.reason -> tgt.reason;
}

group ExplanationOfBenefitCareTeam(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.provider -> tgt.provider;
  src.responsible -> tgt.responsible;
  src.role -> tgt.role;
  src.qualification -> tgt.qualification;
}

group ExplanationOfBenefitDiagnosis(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.diagnosis -> tgt.diagnosis;
  src.type -> tgt.type;
  src.packageCode -> tgt.packageCode;
}

group ExplanationOfBenefitProcedure(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.date -> tgt.date;
  src.procedure -> tgt.procedure;
}

group ExplanationOfBenefitInsurance(source src, target tgt) extends BackboneElement {
  src.coverage -> tgt.coverage;
  src.preAuthRef -> tgt.preAuthRef;
}

group ExplanationOfBenefitAccident(source src, target tgt) extends BackboneElement {
  src.date -> tgt.date;
  src.type -> tgt.type;
  src.location -> tgt.location;
}

group ExplanationOfBenefitItem(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.careTeamLinkId -> tgt.careTeamSequence;
  src.diagnosisLinkId -> tgt.diagnosisSequence;
  src.procedureLinkId -> tgt.procedureSequence;
  src.informationLinkId -> tgt.informationSequence;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.service -> tgt.productOrService;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.encounter -> tgt.encounter;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication as s -> tgt.adjudication as t then ExplanationOfBenefitItemAdjudication(s, t);
  src.detail as s -> tgt.detail as t then ExplanationOfBenefitItemDetail(s, t);
}

group ExplanationOfBenefitItemAdjudication(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.reason -> tgt.reason;
  src.amount -> tgt.amount;
  src.value -> tgt.value;
}

group ExplanationOfBenefitItemDetail(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ExplanationOfBenefitItemDetailSubDetail(s, t);
}

group ExplanationOfBenefitItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ExplanationOfBenefitAddItem(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subDetailSequence -> tgt.subDetailSequence;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.detail as s -> tgt.detail as t then ExplanationOfBenefitAddItemDetail(s, t);
}

group ExplanationOfBenefitAddItemDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ExplanationOfBenefitAddItemDetailSubDetail(s, t);
}

group ExplanationOfBenefitAddItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ExplanationOfBenefitTotalCost(source src, target tgt) extends BackboneElement {
  src ->  tgt.category as cc,  cc.text = 'Submitted Amount',  cc.coding as coding,  coding.code = 'submitted',  coding.system = 'http://terminology.hl7.org/CodeSystem/adjudication' "category";
  src as vs -> tgt.amount as vt then Money(vs, vt) "amount";
}

group ExplanationOfBenefitTotalBenefit(source src, target tgt) extends BackboneElement {
  src ->  tgt.category as cc,  cc.text = 'Benefit Amount',  cc.coding as coding,  coding.code = 'benefit',  coding.system = 'http://terminology.hl7.org/CodeSystem/adjudication' "category";
  src as vs -> tgt.amount as vt then Money(vs, vt) "amount";
}

group ExplanationOfBenefitPayment(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.adjustment -> tgt.adjustment;
  src.adjustmentReason -> tgt.adjustmentReason;
  src.date -> tgt.date;
  src.amount -> tgt.amount;
  src.identifier -> tgt.identifier;
}

group ExplanationOfBenefitProcessNote(source src, target tgt) extends BackboneElement {
  src.number -> tgt.number;
  src.type -> tgt.type;
  src.text -> tgt.text;
  src.language -> tgt.language;
}

group ExplanationOfBenefitBenefitBalance(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.excluded -> tgt.excluded;
  src.name -> tgt.name;
  src.description -> tgt.description;
  src.network -> tgt.network;
  src.unit -> tgt.unit;
  src.term -> tgt.term;
  src.financial as s -> tgt.financial as t then ExplanationOfBenefitBenefitBalanceFinancial(s, t);
}

group ExplanationOfBenefitBenefitBalanceFinancial(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.allowed -> tgt.allowed;
  src.used -> tgt.used;
}

13.10.10.2 R5 to R4

map "http://hl7.org/fhir/StructureMap/ExplanationOfBenefit4to3" = "R4 to R3 Conversion for ExplanationOfBenefit"

uses "http://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit" alias ExplanationOfBenefit as source
uses "http://hl7.org/fhir/3.0/StructureDefinition/ExplanationOfBenefit" alias ExplanationOfBenefitR3 as target

imports "http://hl7.org/fhir/StructureMap/*4to3"

group ExplanationOfBenefit(source src : ExplanationOfBenefit, target tgt : ExplanationOfBenefitR3) extends DomainResource <<type+>> {
  src.identifier -> tgt.identifier;
  src.status -> tgt.status;
  src.type -> tgt.type;
  src.subType -> tgt.subType;
  src.use -> tgt.use;
  src.patient -> tgt.patient;
  src.billablePeriod -> tgt.billablePeriod;
  src.created -> tgt.created;
  src.enterer -> tgt.enterer;
  src.insurer -> tgt.insurer;
  src.provider -> tgt.provider;
  src.referral -> tgt.referral;
  src.facility -> tgt.facility;
  src.claim -> tgt.claim;
  src.claimResponse -> tgt.claimResponse;
  src.outcome as vs where value in ('complete' | 'error' | 'partial') ->  tgt.outcome as vt,  vt.coding as c,  c.system = 'http://hl7.org/fhir/remittance-outcome',  c.code = vs;
  src.disposition -> tgt.disposition;
  src.related as s -> tgt.related as t then ExplanationOfBenefitRelated(s, t);
  src.prescription -> tgt.prescription;
  src.originalPrescription -> tgt.originalPrescription;
  src.payee as s -> tgt.payee as t then ExplanationOfBenefitPayee(s, t);
  src.supportingInfo as s -> tgt.information as t then ExplanationOfBenefitInformation(s, t);
  src.careTeam as s -> tgt.careTeam as t then ExplanationOfBenefitCareTeam(s, t);
  src.diagnosis as s -> tgt.diagnosis as t then ExplanationOfBenefitDiagnosis(s, t);
  src.procedure as s -> tgt.procedure as t then ExplanationOfBenefitProcedure(s, t);
  src.precedence -> tgt.precedence;
  src.insurance as s -> tgt.insurance as t then ExplanationOfBenefitInsurance(s, t);
  src.accident as s -> tgt.accident as t then ExplanationOfBenefitAccident(s, t);
  src.item as s -> tgt.item as t then ExplanationOfBenefitItem(s, t);
  src.addItem as s -> tgt.addItem as t then ExplanationOfBenefitAddItem(s, t);
  src.total as total then {
    total.category as vs then {
      total.amount as va then {
        vs.coding as c where code = 'submitted' then {
          c -> tgt.totalCost as cost then Money(va, cost) "total";
        };
      };
    };
  };
  src.total as total then {
    total.category as vs then {
      total.amount as va then {
        vs.coding as c where code = 'benefit' then {
          c -> tgt.totalBenefit as cost then Money(va, cost) "total";
        };
      };
    };
  };
  src.payment as s -> tgt.payment as t then ExplanationOfBenefitPayment(s, t);
  src.form -> tgt.form;
  src.processNote as s -> tgt.processNote as t then ExplanationOfBenefitProcessNote(s, t);
  src.benefitBalance as s -> tgt.benefitBalance as t then ExplanationOfBenefitBenefitBalance(s, t);
}

group ExplanationOfBenefitRelated(source src, target tgt) extends BackboneElement {
  src.claim -> tgt.claim;
  src.relationship -> tgt.relationship;
  src.reference -> tgt.reference;
}

group ExplanationOfBenefitPayee(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.party -> tgt.party;
}

group ExplanationOfBenefitInformation(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.category -> tgt.category;
  src.code -> tgt.code;
  src.timing -> tgt.timing;
  src.value -> tgt.value;
  src.reason -> tgt.reason;
}

group ExplanationOfBenefitCareTeam(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.provider -> tgt.provider;
  src.responsible -> tgt.responsible;
  src.role -> tgt.role;
  src.qualification -> tgt.qualification;
}

group ExplanationOfBenefitDiagnosis(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.diagnosis -> tgt.diagnosis;
  src.type -> tgt.type;
  src.packageCode -> tgt.packageCode;
}

group ExplanationOfBenefitProcedure(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.date -> tgt.date;
  src.procedure -> tgt.procedure;
}

group ExplanationOfBenefitInsurance(source src, target tgt) extends BackboneElement {
  src.coverage -> tgt.coverage;
  src.preAuthRef -> tgt.preAuthRef;
}

group ExplanationOfBenefitAccident(source src, target tgt) extends BackboneElement {
  src.date -> tgt.date;
  src.type -> tgt.type;
  src.location -> tgt.location;
}

group ExplanationOfBenefitItem(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.careTeamSequence -> tgt.careTeamLinkId;
  src.diagnosisSequence -> tgt.diagnosisLinkId;
  src.procedureSequence -> tgt.procedureLinkId;
  src.informationSequence -> tgt.informationLinkId;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.productOrService -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.encounter -> tgt.encounter;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication as s -> tgt.adjudication as t then ExplanationOfBenefitItemAdjudication(s, t);
  src.detail as s -> tgt.detail as t then ExplanationOfBenefitItemDetail(s, t);
}

group ExplanationOfBenefitItemAdjudication(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.reason -> tgt.reason;
  src.amount -> tgt.amount;
  src.value -> tgt.value;
}

group ExplanationOfBenefitItemDetail(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ExplanationOfBenefitItemDetailSubDetail(s, t);
}

group ExplanationOfBenefitItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.revenue -> tgt.revenue;
  src.category -> tgt.category;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.udi -> tgt.udi;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ExplanationOfBenefitAddItem(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subDetailSequence -> tgt.subDetailSequence;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.detail as s -> tgt.detail as t then ExplanationOfBenefitAddItemDetail(s, t);
}

group ExplanationOfBenefitAddItemDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ExplanationOfBenefitAddItemDetailSubDetail(s, t);
}

group ExplanationOfBenefitAddItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ExplanationOfBenefitPayment(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.adjustment -> tgt.adjustment;
  src.adjustmentReason -> tgt.adjustmentReason;
  src.date -> tgt.date;
  src.amount -> tgt.amount;
  src.identifier -> tgt.identifier;
}

group ExplanationOfBenefitProcessNote(source src, target tgt) extends BackboneElement {
  src.number -> tgt.number;
  src.type -> tgt.type;
  src.text -> tgt.text;
  src.language -> tgt.language;
}

group ExplanationOfBenefitBenefitBalance(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.excluded -> tgt.excluded;
  src.name -> tgt.name;
  src.description -> tgt.description;
  src.network -> tgt.network;
  src.unit -> tgt.unit;
  src.term -> tgt.term;
  src.financial as s -> tgt.financial as t then ExplanationOfBenefitBenefitBalanceFinancial(s, t);
}

group ExplanationOfBenefitBenefitBalanceFinancial(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.allowed -> tgt.allowed;
  src.used -> tgt.used;
}

13.10.10.3 R4 Validation Errors

<p>No validation errors - all conversions are clean</p>