This page is part of the CARIN Blue Button Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions 
SD.5 StructureDefinition-CARIN-BB-ExplanationOfBenefit-Professional-NonClinician
This profile is built upon the CARINBBExplanationOfBenefit Profile. The profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.
SD.5.1 Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/carin-bb-explanationofbenefit-professional-nonclinician
Published on Fri Jul 26 00:00:00 UTC 2019 as a active by CARIN Alliance.
This profile builds on CARINBBExplanationOfBenefit
Summary
Mandatory: 4 elements (5 nested mandatory elements)
Fixed Value: 6 elements
Prohibited: 1 element
Slices
This structure defines the following Slices:
- The element ExplanationOfBenefit.supportingInfo is sliced based on the value of value:category
- The element ExplanationOfBenefit.item.adjudication is sliced based on the value of value:category (Closed)
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
  id | Σ | 1..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | Identifier | Business Identifier for the resource |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required) |
| type | ΣI | 1..1 | CodeableConcept | Category or discipline Binding: CARIN Blue Button Claim Type Value Set (extensible) Required Pattern: At least the following |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 0..1 | uri | Identity of the terminology system | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: professional-nonclinician | |
| display | 0..1 | string | Representation defined by the system | |
 userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
 patient | ΣI | 1..1 | Reference(CARIN Blue Button Patient Profile) | The recipient of the products and services |
| billablePeriod | SΣI | 0..1 | Period | Relevant time frame for the claim |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | ΣI | 1..1 | Reference(CARIN Blue Button Organization Profile) | Party responsible for reimbursement |
| provider | ΣI | 1..1 | Reference(CARIN Blue Button Organization Profile) | Party responsible for the claim |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Prior or corollary claims |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | I | 1..1 | CodeableConcept | How the reference claim is related Binding: CARIN Blue Button Related Claim Relationship Value Set (extensible) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example) |
| party | I | 1..1 | Reference(CARIN Blue Button Practitioner Role Profile | CARIN Blue Button Patient Profile) | Recipient reference |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | I | 1..1 | Reference(CARIN Blue Button Practitioner Role Profile) | Practitioner or organization |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | I | 1..1 | CodeableConcept | Function within the team Binding: CARIN Blue Button Claim Care Team Role Value Set (extensible) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
 supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by value:category |
  supportingInfo:All Slices | Content/Rules for all slices | |||
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
 timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
 reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
 supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (billingnetworkcontractingstatus) |
 id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
 reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (referringnetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:performingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (performingnetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:sitenetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (sitenetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sitenetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 1..1 | BackboneElement | Supporting information |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (clmrecvddate) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 0..* | BackboneElement | Pertinent diagnosis information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | I | 1..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10Codes (example) |
| type | I | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: CARIN Blue Button Diagnosis Type Value Set (extensible) |
| onAdmission | SI | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Clinical procedures performed |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | I | 1..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10ProcedureCodes (example) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | ΣI | 1..2 | (Slice Definition) | Patient insurance information Slice: Unordered, Closed by value:focal |
| insurance:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | ΣI | 1..1 | Reference(CARIN Blue Button Coverage Profile) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| insurance:primaryinsurance | ΣI | 0..1 | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: false |
| coverage | ΣI | 1..1 | Reference(Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| insurance:secondaryinsurance | ΣI | 0..1 | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
| coverage | ΣI | 1..1 | Reference(Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: V3 Value SetActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Item instance identifier |
| careTeamSequence | SI | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | SI | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | SI | 0..* | positiveInt | Applicable procedures |
| informationSequence | SI | 0..* | positiveInt | Applicable exception and supporting information |
| category | SI | 0..1 | CodeableConcept | Benefit classification Binding: CARIN Blue Button Type Of Service Value Set (required) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: CARIN Blue Button CPT/HCPCS Procedure Codes Value Set (required) |
| modifier | SI | 0..* | CodeableConcept | Product or service billing modifiers Binding: CARIN Blue Button HCPCS Modifier Codes Value Set (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | SI | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | SI | 0..1 | CodeableConcept | Place of service or where product was supplied Binding: CARIN Blue Button Place Of Service Codes For Professional Claims Value Set (required) |
| quantity | SI | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | SI | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by value:category |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Claim Adjudication Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Amount Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | I | 0..1 | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example) Fixed Value: As shown (payment denial reason) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: CARIN Blue Button Adjudication Denial Reason Value Set (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Detail level adjudication details | |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Subdetail level adjudication details | |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| adjudication:inoutnetwork | I | 1..1 | BackboneElement | Header-level adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Benefit Payment Status Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 1..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Amount Category Value Set (extensible) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | I | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the variance Binding: CARIN Blue Button Adjudication Denial Reason Value Set (extensible) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
{% include StructureDefinition-CARIN-BB-ExplanationOfBenefit-Professional-NonClinician-pseudo-xml.xhtml %}
{% include StructureDefinition-CARIN-BB-ExplanationOfBenefit-Professional-NonClinician-pseudo-json.xhtml %}
Summary
Mandatory: 4 elements (5 nested mandatory elements)
Fixed Value: 6 elements
Prohibited: 1 element
Slices
This structure defines the following Slices:
- The element ExplanationOfBenefit.supportingInfo is sliced based on the value of value:category
- The element ExplanationOfBenefit.item.adjudication is sliced based on the value of value:category (Closed)
Differential View
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| id | Σ | 1..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | Identifier | Business Identifier for the resource |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required) |
| type | ΣI | 1..1 | CodeableConcept | Category or discipline Binding: CARIN Blue Button Claim Type Value Set (extensible) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 0..1 | uri | Identity of the terminology system | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: professional-nonclinician | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
| patient | ΣI | 1..1 | Reference(CARIN Blue Button Patient Profile) | The recipient of the products and services |
| billablePeriod | SΣI | 0..1 | Period | Relevant time frame for the claim |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | ΣI | 1..1 | Reference(CARIN Blue Button Organization Profile) | Party responsible for reimbursement |
| provider | ΣI | 1..1 | Reference(CARIN Blue Button Organization Profile) | Party responsible for the claim |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Prior or corollary claims |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | I | 1..1 | CodeableConcept | How the reference claim is related Binding: CARIN Blue Button Related Claim Relationship Value Set (extensible) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example) |
| party | I | 1..1 | Reference(CARIN Blue Button Practitioner Role Profile | CARIN Blue Button Patient Profile) | Recipient reference |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | I | 1..1 | Reference(CARIN Blue Button Practitioner Role Profile) | Practitioner or organization |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | I | 1..1 | CodeableConcept | Function within the team Binding: CARIN Blue Button Claim Care Team Role Value Set (extensible) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
| supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by value:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (billingnetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (referringnetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:performingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (performingnetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:sitenetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (sitenetworkcontractingstatus) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sitenetworkcontractingstatus | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: CARIN Blue Button Network Contracting Status Value Set (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 1..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: CARIN Blue Button Claim Information Category Value Set (extensible) Fixed Value: As shown (clmrecvddate) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-claiminformationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 0..* | BackboneElement | Pertinent diagnosis information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | I | 1..1 | CodeableConcept | Nature of illness or problem Binding: ICD-10Codes (example) |
| type | I | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: CARIN Blue Button Diagnosis Type Value Set (extensible) |
| onAdmission | SI | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Clinical procedures performed |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | I | 1..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10ProcedureCodes (example) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | ΣI | 1..2 | (Slice Definition) | Patient insurance information Slice: Unordered, Closed by value:focal |
| insurance:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | ΣI | 1..1 | Reference(CARIN Blue Button Coverage Profile) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| insurance:primaryinsurance | ΣI | 0..1 | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: false |
| coverage | ΣI | 1..1 | Reference(Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| insurance:secondaryinsurance | ΣI | 0..1 | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
| coverage | ΣI | 1..1 | Reference(Coverage) | Insurance information |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: V3 Value SetActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Item instance identifier |
| careTeamSequence | SI | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | SI | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | SI | 0..* | positiveInt | Applicable procedures |
| informationSequence | SI | 0..* | positiveInt | Applicable exception and supporting information |
| category | SI | 0..1 | CodeableConcept | Benefit classification Binding: CARIN Blue Button Type Of Service Value Set (required) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: CARIN Blue Button CPT/HCPCS Procedure Codes Value Set (required) |
| modifier | SI | 0..* | CodeableConcept | Product or service billing modifiers Binding: CARIN Blue Button HCPCS Modifier Codes Value Set (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | SI | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | SI | 0..1 | CodeableConcept | Place of service or where product was supplied Binding: CARIN Blue Button Place Of Service Codes For Professional Claims Value Set (required) |
| quantity | SI | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | SI | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | (Slice Definition) | Adjudication details Slice: Unordered, Closed by value:category |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Claim Adjudication Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Amount Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | I | 0..1 | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example) Fixed Value: As shown (payment denial reason) |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin/CodeSystem/carin-bb-adjudicationcategory | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: CARIN Blue Button Adjudication Denial Reason Value Set (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Detail level adjudication details | |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Subdetail level adjudication details | |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ExplanationOfBenefit.item.adjudication:denialreason Added items adjudication | |
| adjudication:inoutnetwork | I | 1..1 | BackboneElement | Header-level adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Benefit Payment Status Category Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 1..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: CARIN Blue Button Adjudication Amount Category Value Set (extensible) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | I | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the variance Binding: CARIN Blue Button Adjudication Denial Reason Value Set (extensible) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
