This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 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
Defining URL: | http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral |
Version: | 1.2.0 |
Name: | C4BBExplanationOfBenefitOral |
Title: | C4BB ExplanationOfBenefit Oral |
Status: | Active as of 12/6/21 8:26 PM |
Definition: | This profile is used for Explanation of Benefits (EOBs) based on claims submitted by providers of oral services including Dental, Denture and Hygiene. The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. |
Publisher: | HL7 Financial Management Working Group |
Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from C4BBExplanationOfBenefit
Summary
Mandatory: 11 elements (16 nested mandatory elements)
Must-Support: 46 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from C4BBExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | I | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
meta | ||||
profile:supportedProfile | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0 | |
type | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
provider | 1..1 | Reference(C4BB Practitioner) | Party responsible for the claim | |
careTeam | I | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
role | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required) | |
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) |
Slices for supportingInfo | 3..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category | |
supportingInfo:billingnetworkcontractingstatus | S | 1..1 | BackboneElement | Billing provider contracting status |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
supportingInfo:performingnetworkcontractingstatus | S | 1..1 | BackboneElement | Performing provider contracting status |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | S | 1..1 | date | When it occurred |
supportingInfo:servicefacility | S | 0..1 | BackboneElement | Service facility |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
Slices for value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Open by type:$this | |
valueReference | S | 1..1 | Reference(C4BB Organization) | Data to be provided |
supportingInfo:orthodontics | S | 0..1 | BackboneElement | Orthodontics treatment indicator |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
code | 0..1 | CodeableConcept | Type of information | |
timingDate | 0..1 | date | Orthodontics appliance application date (200) | |
Slices for value[x] | S | 1..1 | Quantity | Data to be provided Slice: Unordered, Open by type:$this |
valueQuantity | 1..1 | Quantity | Total number of months for orthodontia | |
supportingInfo:prosthesis | S | 0..1 | BackboneElement | Prosthesis |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
timingDate | 0..1 | date | Date of prior prosthesis replacement (203) | |
Slices for value[x] | S | 1..1 | boolean | Data to be provided Slice: Unordered, Open by type:$this |
valueBoolean | 1..1 | boolean | Prosthesis replacement indicator (202 | |
supportingInfo:additionalbodysite | S | 0..* | BackboneElement | Additional tooth number or oral cavity code |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
code | S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) |
supportingInfo:missingtoothnumber | S | 0..* | BackboneElement | Missing tooth number |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
code | S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
valueString | S | 1..1 | string | Data to be provided |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
valueString | S | 1..1 | string | Data to be provided |
supportingInfo:benefitpaymentstatus | S | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB Payer Benefit Payment Status (required) | |
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required) |
item | ||||
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required) |
serviced[x] | 0..1 | date, Period | Date or dates of service or product delivery | |
Slices for location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Slice: Unordered, Open by type:$this |
locationCodeableConcept | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
bodySite | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) | |
subSite | 0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set (required) | |
Slices for adjudication | S | 2..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 1..* | BackboneElement | Amounts |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:denialreason | S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required) | |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
adjudication | 0..1 | Header-level adjudication | ||
Slices for total | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information |
amount | 1..1 | Money | Financial total for the category | |
total:adjudicationamounttype | S | 1..* | BackboneElement | Total adjudication type and amount |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | I | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
id | Ī£ | 0..1 | string | Logical id of this artifact |
meta | SĪ£ | 1..1 | Meta | Metadata about the resource |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
versionId | Ī£ | 0..1 | id | Version specific identifier |
lastUpdated | SĪ£ | 1..1 | instant | When the resource version last changed |
source | Ī£ | 0..1 | uri | Identifies where the resource comes from |
Slices for profile | Ī£ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this |
profile:supportedProfile | Ī£ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0 |
security | Ī£ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
tag | Ī£ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
implicitRules | ?!Ī£ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | S | 1..* | Identifier | Business Identifier for the resource |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
use | ?!Ī£ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | SĪ£ | 1..1 | CodeableConcept | Description of identifier Binding: C4BB Claim Identifier Type (extensible) |
system | Ī£ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | Ī£ | 0..1 | string | The value that is unique Example General: 123456 |
period | Ī£ | 0..1 | Period | Time period when id is/was valid for use |
assigner | Ī£ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
status | ?!SĪ£ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SĪ£ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
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 | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |
use | SĪ£ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim |
patient | SĪ£ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | SĪ£ | 0..1 | Period | Relevant time frame for the claim |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
start | Ī£I | 0..1 | dateTime | Starting time with inclusive boundary |
end | Ī£I | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
created | Ī£ | 1..1 | dateTime | Response creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |
insurer | SĪ£ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | SĪ£ | 1..1 | Reference(C4BB Practitioner) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |
related | S | 0..* | BackboneElement | Prior or corollary claims |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
claim | 0..1 | Reference(Claim) | Reference to the related claim | |
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes (required) |
reference | S | 1..1 | Identifier | File or case reference |
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |
originalPrescription | 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 | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type (required) |
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner) | Recipient reference |
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |
facility | 0..1 | Reference(Location) | Servicing Facility | |
claim | 0..1 | Reference(Claim) | Claim reference | |
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |
outcome | SĪ£ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
disposition | 0..1 | string | Disposition Message | |
preAuthRef | 0..* | string | Preauthorization reference | |
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |
careTeam | SI | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization |
responsible | 0..1 | boolean | Indicator of the lead practitioner | |
role | S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required) |
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) |
Slices for supportingInfo | S | 3..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category |
supportingInfo:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:billingnetworkcontractingstatus | S | 1..1 | BackboneElement | Billing provider contracting status |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:performingnetworkcontractingstatus | S | 1..1 | BackboneElement | Performing provider contracting status |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | S | 1..1 | date | When it occurred |
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:servicefacility | S | 0..1 | BackboneElement | Service facility |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueReference | S | 1..1 | Reference(C4BB Organization) | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:orthodontics | S | 0..1 | BackboneElement | Orthodontics treatment indicator |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | date | Orthodontics appliance application date (200) | |
Slices for value[x] | S | 1..1 | Quantity | Data to be provided Slice: Unordered, Closed by type:$this |
value[x]:valueQuantity | 1..1 | Quantity | Total number of months for orthodontia | |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:prosthesis | S | 0..1 | BackboneElement | Prosthesis |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | date | Date of prior prosthesis replacement (203) | |
Slices for value[x] | S | 1..1 | boolean | Data to be provided Slice: Unordered, Closed by type:$this |
value[x]:valueBoolean | 1..1 | boolean | Prosthesis replacement indicator (202 | |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:additionalbodysite | S | 0..* | BackboneElement | Additional tooth number or oral cavity code |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:missingtoothnumber | S | 0..* | BackboneElement | Missing tooth number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:benefitpaymentstatus | S | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB Payer Benefit Payment Status (required) | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required) |
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |
procedure | 0..* | BackboneElement | Clinical procedures performed | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
udi | 0..* | Reference(Device) | Unique device identifier | |
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |
insurance | SĪ£I | 1..* | BackboneElement | Patient insurance information |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | SĪ£ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | SĪ£ | 1..1 | Reference(C4BB Coverage) | Insurance information |
preAuthRef | 0..* | string | Prior authorization reference number | |
accident | 0..1 | BackboneElement | Details of the event | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
date | 0..1 | date | When the incident occurred | |
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |
location[x] | 0..1 | Where the event occurred | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
item | S | 1..* | BackboneElement | Product or service provided |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | S | 1..1 | positiveInt | Item instance identifier |
careTeamSequence | 0..* | positiveInt | Applicable care team members | |
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |
procedureSequence | 0..* | positiveInt | Applicable procedures | |
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required) |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
serviced[x] | 0..1 | Date or dates of service or product delivery | ||
servicedDate | date | |||
servicedPeriod | Period | |||
Slices for location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Slice: Unordered, Closed by type:$this Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. |
location[x]:locationCodeableConcept | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
bodySite | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) | |
subSite | 0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set (required) | |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |
noteNumber | S | 0..* | positiveInt | Applicable note numbers |
Slices for adjudication | S | 2..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:adjudicationamounttype | S | 1..* | BackboneElement | Amounts |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | S | 1..1 | Money | Monetary amount |
value | 0..1 | decimal | Non-monitary value | |
adjudication:denialreason | S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
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 | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
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 | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
detail | 0..* | BackboneElement | Additional items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Product or service provided | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Additional items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Product or service provided | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |
addItem | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
itemSequence | 0..* | positiveInt | Item sequence number | |
detailSequence | 0..* | positiveInt | Detail sequence number | |
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
serviced[x] | 0..1 | Date or dates of service or product delivery | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
detail | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
subDetail | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
adjudication | 0..1 | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |
Slices for total | SĪ£ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SĪ£ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
amount | Ī£ | 1..1 | Money | Financial total for the category |
total:adjudicationamounttype | SĪ£ | 1..* | BackboneElement | Total adjudication type and amount |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Ī£ | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) |
amount | Ī£ | 1..1 | Money | Financial total for the category |
payment | S | 0..1 | BackboneElement | Payment Details |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code (required) |
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |
date | 0..1 | date | Expected date of payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Business identifier for the payment | |
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |
form | 0..1 | Attachment | Printed reference or actual form | |
processNote | S | 0..* | BackboneElement | Note concerning adjudication |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
number | 0..1 | positiveInt | Note instance identifier | |
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |
text | 0..1 | string | Note explanatory text | |
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
benefitPeriod | 0..1 | Period | When the benefits are applicable | |
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
excluded | 0..1 | boolean | Excluded from the plan | |
name | 0..1 | string | Short name for the benefit | |
description | 0..1 | string | Description of the benefit or services covered | |
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |
financial | 0..* | BackboneElement | Benefit Summary | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |
allowed[x] | 0..1 | Benefits allowed | ||
allowedUnsignedInt | unsignedInt | |||
allowedString | string | |||
allowedMoney | Money | |||
used[x] | 0..1 | Benefits used | ||
usedUnsignedInt | unsignedInt | |||
usedMoney | Money | |||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | I | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
meta | Ī£ | 1..1 | Meta | Metadata about the resource |
lastUpdated | Ī£ | 1..1 | instant | When the resource version last changed |
identifier | 1..* | Identifier | Business Identifier for the resource | |
type | Ī£ | 1..1 | CodeableConcept | Description of identifier Binding: C4BB Claim Identifier Type (extensible) |
status | ?!Ī£ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | Ī£ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
use | Ī£ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim |
patient | Ī£ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | Ī£ | 0..1 | Period | Relevant time frame for the claim |
insurer | Ī£ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | Ī£ | 1..1 | Reference(C4BB Practitioner) | Party responsible for the claim |
related | 0..* | BackboneElement | Prior or corollary claims | |
relationship | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes (required) | |
reference | 1..1 | Identifier | File or case reference | |
payee | I | 0..1 | BackboneElement | Recipient of benefits payable |
type | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type (required) | |
party | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner) | Recipient reference | |
outcome | Ī£ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
careTeam | I | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
provider | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | |
role | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required) | |
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) | |
Slices for supportingInfo | 3..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category | |
supportingInfo:billingnetworkcontractingstatus | 1..1 | BackboneElement | Billing provider contracting status | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
code | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) | |
supportingInfo:performingnetworkcontractingstatus | 1..1 | BackboneElement | Performing provider contracting status | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
code | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) | |
supportingInfo:clmrecvddate | 0..1 | BackboneElement | Claim received date | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | 1..1 | date | When it occurred | |
supportingInfo:servicefacility | 0..1 | BackboneElement | Service facility | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
value[x]:valueReference | 1..1 | Reference(C4BB Organization) | Data to be provided | |
supportingInfo:orthodontics | 0..1 | BackboneElement | Orthodontics treatment indicator | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
Slices for value[x] | 1..1 | Quantity | Data to be provided Slice: Unordered, Closed by type:$this | |
supportingInfo:prosthesis | 0..1 | BackboneElement | Prosthesis | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
Slices for value[x] | 1..1 | boolean | Data to be provided Slice: Unordered, Closed by type:$this | |
supportingInfo:additionalbodysite | 0..* | BackboneElement | Additional tooth number or oral cavity code | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
code | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) | |
supportingInfo:missingtoothnumber | 0..* | BackboneElement | Missing tooth number | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
code | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) | |
supportingInfo:medicalrecordnumber | 0..1 | BackboneElement | Medical record number | |
value[x]:valueString | 1..1 | string | Data to be provided | |
supportingInfo:patientaccountnumber | 0..1 | BackboneElement | Patient account number | |
value[x]:valueString | 1..1 | string | Data to be provided | |
supportingInfo:benefitpaymentstatus | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) | |
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |
diagnosis[x] | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required) | |
type | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required) | |
insurance | Ī£I | 1..* | BackboneElement | Patient insurance information |
focal | Ī£ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Ī£ | 1..1 | Reference(C4BB Coverage) | Insurance information |
item | 1..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature (required) | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required) | |
Slices for location[x] | 1..1 | CodeableConcept | Place of service or where product was supplied Slice: Unordered, Closed by type:$this Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
Slices for adjudication | 2..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category | |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | 1..* | BackboneElement | Amounts | |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) | |
amount | 1..1 | Money | Monetary amount | |
adjudication:denialreason | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) | |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | |
adjudication:benefitpaymentstatus | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) | |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required) | |
adjudication:allowedunits | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) | |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
Slices for total | Ī£ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
category | Ī£ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
total:adjudicationamounttype | Ī£ | 1..* | BackboneElement | Total adjudication type and amount |
payment | 0..1 | BackboneElement | Payment Details | |
type | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code (required) | |
processNote | 0..* | BackboneElement | Note concerning adjudication | |
Documentation for this format |
This structure is derived from C4BBExplanationOfBenefit
Summary
Mandatory: 11 elements (16 nested mandatory elements)
Must-Support: 46 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from C4BBExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | I | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
meta | ||||
profile:supportedProfile | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0 | |
type | 1..1 | CodeableConcept | Category or discipline Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
provider | 1..1 | Reference(C4BB Practitioner) | Party responsible for the claim | |
careTeam | I | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
role | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required) | |
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) |
Slices for supportingInfo | 3..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category | |
supportingInfo:billingnetworkcontractingstatus | S | 1..1 | BackboneElement | Billing provider contracting status |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
supportingInfo:performingnetworkcontractingstatus | S | 1..1 | BackboneElement | Performing provider contracting status |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
timing[x] | S | 1..1 | date | When it occurred |
supportingInfo:servicefacility | S | 0..1 | BackboneElement | Service facility |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
Slices for value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Open by type:$this | |
valueReference | S | 1..1 | Reference(C4BB Organization) | Data to be provided |
supportingInfo:orthodontics | S | 0..1 | BackboneElement | Orthodontics treatment indicator |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
code | 0..1 | CodeableConcept | Type of information | |
timingDate | 0..1 | date | Orthodontics appliance application date (200) | |
Slices for value[x] | S | 1..1 | Quantity | Data to be provided Slice: Unordered, Open by type:$this |
valueQuantity | 1..1 | Quantity | Total number of months for orthodontia | |
supportingInfo:prosthesis | S | 0..1 | BackboneElement | Prosthesis |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
timingDate | 0..1 | date | Date of prior prosthesis replacement (203) | |
Slices for value[x] | S | 1..1 | boolean | Data to be provided Slice: Unordered, Open by type:$this |
valueBoolean | 1..1 | boolean | Prosthesis replacement indicator (202 | |
supportingInfo:additionalbodysite | S | 0..* | BackboneElement | Additional tooth number or oral cavity code |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
code | S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) |
supportingInfo:missingtoothnumber | S | 0..* | BackboneElement | Missing tooth number |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
code | S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
valueString | S | 1..1 | string | Data to be provided |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Open by type:$this | |
valueString | S | 1..1 | string | Data to be provided |
supportingInfo:benefitpaymentstatus | S | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB Payer Benefit Payment Status (required) | |
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required) |
item | ||||
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required) |
serviced[x] | 0..1 | date, Period | Date or dates of service or product delivery | |
Slices for location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Slice: Unordered, Open by type:$this |
locationCodeableConcept | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
bodySite | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) | |
subSite | 0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set (required) | |
Slices for adjudication | S | 2..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 1..* | BackboneElement | Amounts |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:denialreason | S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required) | |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
adjudication | 0..1 | Header-level adjudication | ||
Slices for total | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |
total:All Slices | Content/Rules for all slices | |||
category | S | 1..1 | CodeableConcept | Type of adjudication information |
amount | 1..1 | Money | Financial total for the category | |
total:adjudicationamounttype | S | 1..* | BackboneElement | Total adjudication type and amount |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) | |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | I | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource Oral-EOB-surface-subsite-requires-tooth-number: If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] |
id | Ī£ | 0..1 | string | Logical id of this artifact |
meta | SĪ£ | 1..1 | Meta | Metadata about the resource |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
versionId | Ī£ | 0..1 | id | Version specific identifier |
lastUpdated | SĪ£ | 1..1 | instant | When the resource version last changed |
source | Ī£ | 0..1 | uri | Identifies where the resource comes from |
Slices for profile | Ī£ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this |
profile:supportedProfile | Ī£ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|1.2.0 |
security | Ī£ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
tag | Ī£ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
implicitRules | ?!Ī£ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | S | 1..* | Identifier | Business Identifier for the resource |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
use | ?!Ī£ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
type | SĪ£ | 1..1 | CodeableConcept | Description of identifier Binding: C4BB Claim Identifier Type (extensible) |
system | Ī£ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
value | Ī£ | 0..1 | string | The value that is unique Example General: 123456 |
period | Ī£ | 0..1 | Period | Time period when id is/was valid for use |
assigner | Ī£ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
status | ?!SĪ£ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SĪ£ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: oral | |
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 | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |
use | SĪ£ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim |
patient | SĪ£ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services |
billablePeriod | SĪ£ | 0..1 | Period | Relevant time frame for the claim |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
start | Ī£I | 0..1 | dateTime | Starting time with inclusive boundary |
end | Ī£I | 0..1 | dateTime | End time with inclusive boundary, if not ongoing |
created | Ī£ | 1..1 | dateTime | Response creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |
insurer | SĪ£ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement |
provider | SĪ£ | 1..1 | Reference(C4BB Practitioner) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |
related | S | 0..* | BackboneElement | Prior or corollary claims |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
claim | 0..1 | Reference(Claim) | Reference to the related claim | |
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BB Related Claim Relationship Codes (required) |
reference | S | 1..1 | Identifier | File or case reference |
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |
originalPrescription | 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 | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BB Payee Type (required) |
party | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner) | Recipient reference |
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |
facility | 0..1 | Reference(Location) | Servicing Facility | |
claim | 0..1 | Reference(Claim) | Claim reference | |
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |
outcome | SĪ£ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
disposition | 0..1 | string | Disposition Message | |
preAuthRef | 0..* | string | Preauthorization reference | |
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | |
careTeam | SI | 0..* | BackboneElement | Care Team members EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization |
responsible | 0..1 | boolean | Indicator of the lead practitioner | |
role | S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Professional And Non Clinician Care Team Role (required) |
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) |
Slices for supportingInfo | S | 3..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category |
supportingInfo:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:billingnetworkcontractingstatus | S | 1..1 | BackboneElement | Billing provider contracting status |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:performingnetworkcontractingstatus | S | 1..1 | BackboneElement | Performing provider contracting status |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: performingnetworkcontractingstatus | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: C4BB Payer Provider Contracting Status (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:clmrecvddate | S | 0..1 | BackboneElement | Claim received date |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | S | 1..1 | date | When it occurred |
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:servicefacility | S | 0..1 | BackboneElement | Service facility |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: servicefacility | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | Reference(Resource) | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueReference | S | 1..1 | Reference(C4BB Organization) | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:orthodontics | S | 0..1 | BackboneElement | Orthodontics treatment indicator |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: orthodontics | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | date | Orthodontics appliance application date (200) | |
Slices for value[x] | S | 1..1 | Quantity | Data to be provided Slice: Unordered, Closed by type:$this |
value[x]:valueQuantity | 1..1 | Quantity | Total number of months for orthodontia | |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:prosthesis | S | 0..1 | BackboneElement | Prosthesis |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (extensible) Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: prosthesis | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | date | Date of prior prosthesis replacement (203) | |
Slices for value[x] | S | 1..1 | boolean | Data to be provided Slice: Unordered, Closed by type:$this |
value[x]:valueBoolean | 1..1 | boolean | Prosthesis replacement indicator (202 | |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:additionalbodysite | S | 0..* | BackboneElement | Additional tooth number or oral cavity code |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalbodysite | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: Oral Body Site Value Set (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:missingtoothnumber | S | 0..* | BackboneElement | Missing tooth number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: missingtoothnumber | |
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 | |
code | S | 1..1 | CodeableConcept | Type of information Binding: American Dental Association Universal Numbering Value Set (required) |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:medicalrecordnumber | S | 0..1 | BackboneElement | Medical record number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: medicalrecordnumber | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:patientaccountnumber | S | 0..1 | BackboneElement | Patient account number |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB SupportingInfo Type (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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientaccountnumber | |
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 | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
Slices for value[x] | 1..1 | string | Data to be provided Slice: Unordered, Closed by type:$this | |
value[x]:valueString | S | 1..1 | string | Data to be provided |
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
supportingInfo:benefitpaymentstatus | S | 1..* | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BB Payer Benefit Payment Status (required) | |
code | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Resource) | |||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required) |
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required) |
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |
procedure | 0..* | BackboneElement | Clinical procedures performed | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
udi | 0..* | Reference(Device) | Unique device identifier | |
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |
insurance | SĪ£I | 1..* | BackboneElement | Patient insurance information |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | SĪ£ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | SĪ£ | 1..1 | Reference(C4BB Coverage) | Insurance information |
preAuthRef | 0..* | string | Prior authorization reference number | |
accident | 0..1 | BackboneElement | Details of the event | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
date | 0..1 | date | When the incident occurred | |
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |
location[x] | 0..1 | Where the event occurred | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
item | S | 1..* | BackboneElement | Product or service provided |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | S | 1..1 | positiveInt | Item instance identifier |
careTeamSequence | 0..* | positiveInt | Applicable care team members | |
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |
procedureSequence | 0..* | positiveInt | Applicable procedures | |
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ADA Code on Dental Procedures and Nomenclature (required) |
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required) |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
serviced[x] | 0..1 | Date or dates of service or product delivery | ||
servicedDate | date | |||
servicedPeriod | Period | |||
Slices for location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Slice: Unordered, Closed by type:$this Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. |
location[x]:locationCodeableConcept | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: CMS Place of Service Codes (POS) (required) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
bodySite | 0..1 | CodeableConcept | First tooth number or oral cavity code Binding: Oral Body Site Value Set (required) | |
subSite | 0..* | CodeableConcept | Tooth surface for all teeth on line Binding: US Surface Codes Set (required) | |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |
noteNumber | S | 0..* | positiveInt | Applicable note numbers |
Slices for adjudication | S | 2..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication Category Discriminator (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:adjudicationamounttype | S | 1..* | BackboneElement | Amounts |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | S | 1..1 | Money | Monetary amount |
value | 0..1 | decimal | Non-monitary value | |
adjudication:denialreason | S | 0..1 | BackboneElement | Reason codes used to interpret the Non-Covered Amount (92) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
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 | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:benefitpaymentstatus | S | 1..1 | BackboneElement | Indicates the in network or out of network payment status of the claim. (142) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Payer Benefit Payment Status (required) |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
adjudication:allowedunits | S | 0..1 | BackboneElement | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
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 | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monitary value | |
detail | 0..* | BackboneElement | Additional items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Product or service provided | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Additional items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Product or service provided | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |
addItem | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
itemSequence | 0..* | positiveInt | Item sequence number | |
detailSequence | 0..* | positiveInt | Detail sequence number | |
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
serviced[x] | 0..1 | Date or dates of service or product delivery | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
detail | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
subDetail | 0..* | BackboneElement | Insurer added line items | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | Applicable note numbers | |
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |
adjudication | 0..1 | See adjudication (ExplanationOfBenefit) | Header-level adjudication | |
Slices for total | SĪ£ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category |
total:All Slices | Content/Rules for all slices | |||
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SĪ£ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
amount | Ī£ | 1..1 | Money | Financial total for the category |
total:adjudicationamounttype | SĪ£ | 1..* | BackboneElement | Total adjudication type and amount |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Ī£ | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Adjudication (required) |
amount | Ī£ | 1..1 | Money | Financial total for the category |
payment | S | 0..1 | BackboneElement | Payment Details |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BB Payer Claim Payment Status Code (required) |
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |
date | 0..1 | date | Expected date of payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Business identifier for the payment | |
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |
form | 0..1 | Attachment | Printed reference or actual form | |
processNote | S | 0..* | BackboneElement | Note concerning adjudication |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
number | 0..1 | positiveInt | Note instance identifier | |
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |
text | 0..1 | string | Note explanatory text | |
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
benefitPeriod | 0..1 | Period | When the benefits are applicable | |
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |
excluded | 0..1 | boolean | Excluded from the plan | |
name | 0..1 | string | Short name for the benefit | |
description | 0..1 | string | Description of the benefit or services covered | |
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |
financial | 0..* | BackboneElement | Benefit Summary | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Ī£ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |
allowed[x] | 0..1 | Benefits allowed | ||
allowedUnsignedInt | unsignedInt | |||
allowedString | string | |||
allowedMoney | Money | |||
used[x] | 0..1 | Benefits used | ||
usedUnsignedInt | unsignedInt | |||
usedMoney | Money | |||
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
ExplanationOfBenefit.meta.security | extensible | All Security Labels |
ExplanationOfBenefit.meta.tag | example | CommonTags |
ExplanationOfBenefit.language | preferred | CommonLanguages Max Binding: AllLanguages |
ExplanationOfBenefit.identifier.use | required | IdentifierUse |
ExplanationOfBenefit.identifier.type | extensible | C4BBClaimIdentifierType |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus |
ExplanationOfBenefit.type | required | Pattern: oral |
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodes |
ExplanationOfBenefit.use | required | Pattern: claim |
ExplanationOfBenefit.priority | required | ProcessPriorityCodes |
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes |
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes |
ExplanationOfBenefit.related.relationship | required | C4BBRelatedClaimRelationshipCodes |
ExplanationOfBenefit.payee.type | required | C4BBPayeeType |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodes |
ExplanationOfBenefit.careTeam.role | required | C4BBClaimProfessionalAndNonClinicianCareTeamRole |
ExplanationOfBenefit.careTeam.qualification | required | HealthcareProviderTaxonomy |
ExplanationOfBenefit.supportingInfo.category | extensible | C4BBSupportingInfoType |
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.category | extensible | Pattern: billingnetworkcontractingstatus |
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.code | required | C4BBPayerProviderContractingStatus |
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.category | extensible | Pattern: performingnetworkcontractingstatus |
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.code | required | C4BBPayerProviderContractingStatus |
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:clmrecvddate.category | extensible | Pattern: clmrecvddate |
ExplanationOfBenefit.supportingInfo:clmrecvddate.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:clmrecvddate.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:servicefacility.category | extensible | Pattern: servicefacility |
ExplanationOfBenefit.supportingInfo:servicefacility.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:servicefacility.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:orthodontics.category | extensible | Pattern: orthodontics |
ExplanationOfBenefit.supportingInfo:orthodontics.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:orthodontics.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:prosthesis.category | extensible | Pattern: prosthesis |
ExplanationOfBenefit.supportingInfo:prosthesis.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:prosthesis.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:additionalbodysite.category | extensible | Pattern: additionalbodysite |
ExplanationOfBenefit.supportingInfo:additionalbodysite.code | required | OralBodySite |
ExplanationOfBenefit.supportingInfo:additionalbodysite.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.category | extensible | Pattern: missingtoothnumber |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.code | required | ADAUniversalNumberingSystem |
ExplanationOfBenefit.supportingInfo:missingtoothnumber.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.category | extensible | Pattern: medicalrecordnumber |
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:patientaccountnumber.category | extensible | Pattern: patientaccountnumber |
ExplanationOfBenefit.supportingInfo:patientaccountnumber.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.supportingInfo:benefitpaymentstatus.category | required | C4BBPayerBenefitPaymentStatus |
ExplanationOfBenefit.supportingInfo:benefitpaymentstatus.code | example | ExceptionCodes |
ExplanationOfBenefit.supportingInfo:benefitpaymentstatus.reason | example | MissingToothReasonCodes |
ExplanationOfBenefit.diagnosis.diagnosis[x] | required | CDCICD910CMDiagnosisCodes |
ExplanationOfBenefit.diagnosis.type | required | C4BBClaimProfessionalAndNonClinicianDiagnosisType |
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes |
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes |
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes |
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes |
ExplanationOfBenefit.accident.type | extensible | ActIncidentCode |
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodes |
ExplanationOfBenefit.item.category | example | BenefitCategoryCodes |
ExplanationOfBenefit.item.productOrService | required | ADADentalProcedureCode |
ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSModifiers |
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes |
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes |
ExplanationOfBenefit.item.location[x]:locationCodeableConcept | required | CMSPlaceofServiceCodes |
ExplanationOfBenefit.item.bodySite | required | OralBodySite |
ExplanationOfBenefit.item.subSite | required | C4BBSurfaceCodes |
ExplanationOfBenefit.item.adjudication.category | required | C4BBAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | C4BBAdjudication |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes |
ExplanationOfBenefit.item.adjudication:denialreason.category | example | Pattern: denialreason |
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.category | required | C4BBPayerBenefitPaymentStatus |
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reason | example | AdjudicationReasonCodes |
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunits |
ExplanationOfBenefit.item.adjudication:allowedunits.reason | example | AdjudicationReasonCodes |
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes |
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes |
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes |
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes |
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes |
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes |
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes |
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes |
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes |
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes |
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes |
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes |
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes |
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes |
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes |
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes |
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes |
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes |
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes |
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes |
ExplanationOfBenefit.total.category | example | AdjudicationValueCodes |
ExplanationOfBenefit.total:adjudicationamounttype.category | required | C4BBAdjudication |
ExplanationOfBenefit.payment.type | required | C4BBPayerClaimPaymentStatusCode |
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes |
ExplanationOfBenefit.formCode | example | Form Codes |
ExplanationOfBenefit.processNote.type | required | NoteType |
ExplanationOfBenefit.processNote.language | preferred | CommonLanguages Max Binding: AllLanguages |
ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes |
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes |
ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes |
ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes |
ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes |
Id | Path | Details | Requirements |
Oral-EOB-surface-subsite-requires-tooth-number | ExplanationOfBenefit | If item.subsite (tooth surface) exists then tooth number is required in bodySite or supportingInfo[additionalBodySite] : item.where(subSite.exists() and (bodySite.where(coding.system='https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL').exists().not() and informationSequence.combine(%context.supportingInfo.where(code.coding.system='https://ada.org/ToothNumberingSystem-TEMPORARY-WAITING-FOR-HTA-DEFINED-URL' and category.coding.code = 'additionalbodysite').sequence).isDistinct())).count() = 0 | |
EOB-prof-careTeam-practitioner | ExplanationOfBenefit.careTeam | Professional EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('performing' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('performing' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner) ) |