Notes on Fields

• The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
• CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts and amount types of the claim are to be provided in EOB.total.  The in network or out of network payment status of the claim are to be provided in EOB.supportingInfo.
• ExplanationOfBenefit.item.productOrService:  values are NDC Codes when Compound Code (MapID 78) = 0 or 1.  When the Compound Code = 2, productOrService = "compound" and map the ingredient to ExplanationOfBenefit.item.detail.productOrService
• ExplanationOfBenefit.item.productOrService and item.detail.productOrService: Payers shall provide an 11-digit NDC. For additional information, reference the Other useful Information in the HL7 Terminology Authority - External Terminologies - NDC Confluence site, https://confluence.hl7.org/pages/viewpage.action?pageId=97453858
• ExplanationOfBenefit.item.quantity:  populate for all Compound Code values.  When the Compound Code = 2, if available, map the ingredient to ExplanationOfBenefit.item.detail.quantity
• ExplanationOfBenefit.item.adjudication.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient).  The eligible amount - the member liability is the payment amount to the provider (paidtoprovider). 
• ExplanationOfBenefit.total.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient).  The eligible amount - the member liability is the payment amount to the provider (paidtoprovider). 
• ExplanationOfBenefit.supportingInfo[benefitpaymentstatus]:  in network or out of network payment status for the claim
• The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
• meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from C4BBExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource
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-Pharmacy|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: pharmacy
created	S	1..1	dateTime	Response creation date
careTeam	I	0..*	BackboneElement	Care Team members EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
role		1..1	CodeableConcept	Function within the team Binding: C4BB Claim Pharmacy CareTeam Roles (required)
Slices for supportingInfo		5..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:dayssupply	S	1..1	BackboneElement	Supporting information
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: dayssupply
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:dawcode	S	1..1	BackboneElement	Supporting information
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: dawcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Dispense As Written (DAW)/Product Selection Code (required)
supportingInfo:refillNum	S	1..1	BackboneElement	Supporting information
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: refillnum
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:refillsAuthorized		1..1	BackboneElement	Supporting information
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: refillsauthorized
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:billingnetworkcontractingstatus	S	0..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:brandgenericindicator	S	0..1	BackboneElement	Supporting information
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: brandgenericindicator
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Brand Generic Indicator (required)
supportingInfo:rxoriginCode	S	0..1	BackboneElement	Supporting information
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: rxorigincode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Prescription Origin Code (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:compoundcode	S	0..1	BackboneElement	Supporting information
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: compoundcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Compound Code (required)
supportingInfo:benefitpaymentstatus	S	1..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)
item
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: NDC or Compound (required)
serviced[x]	S	1..1	date, Period	Date or dates of service or product delivery
quantity	S	0..1	SimpleQuantity	Count of products or services
Slices for adjudication	S	1..*	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	Line level adjudication type and amount
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: NCPDP Reject Code (required)
detail	S	0..*	BackboneElement	Additional items
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: National Drug Code (NDC) (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
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 Binding: C4BB Total Category Discriminator (extensible)
amount	S	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)
amount	S	1..1	Money	Financial total for the category
payment
date	S	0..1	date	Expected date of payment
processNote
text	S	0..1	string	Note explanatory text
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource
id	Σ	0..1	string	Logical id of this artifact
meta	SΣ	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	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
Slices for profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Pharmacy|1.2.0
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	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	?!Σ	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	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	SΣ	1..1	CodeableConcept	Description of identifier Binding: C4BB Claim Identifier Type (extensible)
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	SΣ	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: pharmacy
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	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim
patient	SΣ	1..1	Reference(C4BB Patient)	The recipient of the products and services
billablePeriod	SΣ	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	ΣI	0..1	dateTime	Starting time with inclusive boundary
end	ΣI	0..1	dateTime	End time with inclusive boundary, if not ongoing
created	SΣ	1..1	dateTime	Response creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(C4BB Organization)	Party responsible for reimbursement
provider	SΣ	1..1	Reference(C4BB Organization | 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	?!Σ	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	?!Σ	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	SΣ	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-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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 Pharmacy CareTeam Roles (required)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
Slices for supportingInfo	S	5..*	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	?!Σ	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:dayssupply	S	1..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: dayssupply
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
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:dawcode	S	1..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: dawcode
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: NCPDP Dispense As Written (DAW)/Product Selection Code (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:refillNum	S	1..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: refillnum
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
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:refillsAuthorized	S	1..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: refillsauthorized
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
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:billingnetworkcontractingstatus	S	0..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	?!Σ	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:brandgenericindicator	S	0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: brandgenericindicator
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: NCPDP Brand Generic Indicator (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:rxoriginCode	S	0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: rxorigincode
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: NCPDP Prescription Origin Code (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	?!Σ	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:compoundcode	S	0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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: compoundcode
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: NCPDP Compound Code (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: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	?!Σ	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		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
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	?!Σ	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	SΣI	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication
coverage	SΣ	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	?!Σ	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	?!Σ	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		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: NDC or Compound (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	1..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	S	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	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.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
noteNumber	S	0..*	positiveInt	Applicable note numbers
Slices for adjudication	S	1..*	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	?!Σ	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	Line level adjudication type and amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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	?!Σ	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: NCPDP Reject Code (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
detail	S	0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	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	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: National Drug Code (NDC) (required)
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	S	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	?!Σ	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	?!Σ	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	?!Σ	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	?!Σ	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	SΣ	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	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Total Category Discriminator (extensible)
amount	SΣ	1..1	Money	Financial total for the category
total:adjudicationamounttype	SΣ	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	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication (required)
amount	SΣ	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	?!Σ	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	S	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	?!Σ	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	S	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	?!Σ	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	?!Σ	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