CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue ButtonĀ®)
1.2.0 - STU 2 Ballot

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

Resource Profile: C4BB ExplanationOfBenefit Professional NonClinician

Defining URL:http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician
Version:1.2.0
Name:C4BBExplanationOfBenefitProfessionalNonClinician
Title:C4BB ExplanationOfBenefit Professional NonClinician
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 physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.

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-Professional-NonClinician

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, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total If there is a mix of lines paid in network and out of network on a claim, the value of C4BB Payer Benefit Payment Status is ‘Other’
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indiate any order in which the diagnosis was reported or identified.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of diagnosis.type to identify primary, secondary, etc. 
  • .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
  • .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
  • .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
  • .item.productOrService:   CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on a professional / non-clinician claim . The cardinality of the HL7 base EOB Resource for .item.revenue is 1..1 if .item is provided. Since item.productOrService is required it means that .item.revenue must be populated. Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason for item.revenue.
  • A CPT / HCPCS code may not be available on a professional nonclinician vision claim (vision only). The cardinality of the HL7 base EOB Resource for item.productOrService is 1..1 if .item is provided.  Since .item.revenue is required it means that item.productOrService must be populated.  Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason when a CPT / HCPCS or code is not available.
  • item.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the line
  • .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  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) or the subscriber (paidtopatient)
  • .item.adjudication[benefitpaymentstatus]:  place in network or out of network payment status here
  • .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  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) or the subscriber (paidtopatient)
  • 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.

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 10 elements (11 nested mandatory elements)
Must-Support: 32 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.supportingInfo.value[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.location[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... meta
.... profile:supportedProfile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0
... type 1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: C4BB Professional And Non Clinician Claim SubType (required)
... careTeam I0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus S0..1BackboneElementBilling provider contracting status
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:performingnetworkcontractingstatus S0..1BackboneElementPerforming provider contracting status
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Open by type:$this
..... valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
... item
.... productOrService SI1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required)
.... serviced[x] 1..1date, PeriodDate or dates of service or product delivery
.... Slices for location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:denialreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
..... adjudication:allowedunits S0..1BackboneElementThe 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..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... adjudication 0..1Header-level adjudication
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (extensible)
..... amount 1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... id Ī£0..1stringLogical id of this artifact
... meta SĪ£1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies 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..1canonical(StructureDefinition)Profiles this resource claims to conform to

Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0
.... security Ī£0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Ī£0..*CodingTags 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..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SĪ£1..1CodeableConceptDescription of identifier
Binding: C4BB Claim Identifier Type (extensible)
.... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Ī£0..1stringThe value that is unique
Example General: 123456
.... period Ī£0..1PeriodTime period when id is/was valid for use
.... assigner Ī£0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: C4BB Professional And Non Clinician Claim SubType (required)
... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start Ī£I0..1dateTimeStarting time with inclusive boundary
.... end Ī£I0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Ī£1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes (required)
.... reference S1..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:billingnetworkcontractingstatus S0..1BackboneElementBilling provider contracting status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:performingnetworkcontractingstatus S0..1BackboneElementPerforming provider contracting status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1dateWhen it occurred
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S1..1Reference(C4BB Organization)Data to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S1..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£I1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService SI1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 1..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... Slices for location[x] S1..1CodeableConceptPlace 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..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical 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 S0..*positiveIntApplicable note numbers
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:denialreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:allowedunits S0..1BackboneElementThe 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..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... adjudication 0..1See adjudication (ExplanationOfBenefit)Header-level adjudication
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (extensible)
..... amount Ī£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount Ī£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... meta Ī£1..1MetaMetadata about the resource
.... lastUpdated Ī£1..1instantWhen the resource version last changed
... identifier 1..*IdentifierBusiness Identifier for the resource
.... type Ī£1..1CodeableConceptDescription of identifier
Binding: C4BB Claim Identifier Type (extensible)
... status ?!Ī£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... use Ī£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient Ī£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod Ī£1..1PeriodRelevant time frame for the claim
... insurer Ī£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider Ī£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... related 0..*BackboneElementPrior or corollary claims
.... relationship 1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes (required)
.... reference 1..1IdentifierFile or case reference
... payee I0..1BackboneElementRecipient of benefits payable
.... type 1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type (required)
.... party 0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... outcome Ī£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam I0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... provider 1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementBilling provider contracting status
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:performingnetworkcontractingstatus 0..1BackboneElementPerforming provider contracting status
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
..... code 1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:clmrecvddate 0..1BackboneElementClaim received date
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] 1..1dateWhen it occurred
.... supportingInfo:servicefacility 0..1BackboneElementService facility
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... value[x]:valueReference 1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:medicalrecordnumber 0..1BackboneElementMedical record number
..... value[x]:valueString 1..1stringData to be provided
.... supportingInfo:patientaccountnumber 0..1BackboneElementPatient account number
..... value[x]:valueString 1..1stringData to be provided
... diagnosis 1..*BackboneElementPertinent diagnosis information
.... diagnosis[x] 1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
.... type 1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
... insurance Ī£I1..*BackboneElementPatient insurance information
.... focal Ī£1..1booleanCoverage to be used for adjudication
.... coverage Ī£1..1Reference(C4BB Coverage)Insurance information
... item 1..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... productOrService I1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required)
.... Slices for location[x] 1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

.... noteNumber 0..*positiveIntApplicable note numbers
.... Slices for adjudication 2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype 1..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount 1..1MoneyMonetary amount
..... adjudication:denialreason 0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason 1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
..... adjudication:benefitpaymentstatus 1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
..... adjudication:allowedunits 0..1BackboneElementThe 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..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for total Ī£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (extensible)
.... total:adjudicationamounttype Ī£1..*BackboneElementTotal adjudication type and amount
... payment 0..1BackboneElementPayment Details
.... type 0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
... processNote 0..*BackboneElementNote concerning adjudication

doco Documentation for this format

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 10 elements (11 nested mandatory elements)
Must-Support: 32 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element ExplanationOfBenefit.supportingInfo is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.supportingInfo.value[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.location[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

Differential View

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... meta
.... profile:supportedProfile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0
... type 1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: C4BB Professional And Non Clinician Claim SubType (required)
... careTeam I0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus S0..1BackboneElementBilling provider contracting status
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:performingnetworkcontractingstatus S0..1BackboneElementPerforming provider contracting status
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Open by type:$this
..... valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
... item
.... productOrService SI1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required)
.... serviced[x] 1..1date, PeriodDate or dates of service or product delivery
.... Slices for location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:denialreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
..... adjudication:allowedunits S0..1BackboneElementThe 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..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... adjudication 0..1Header-level adjudication
... Slices for total 1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (extensible)
..... amount 1..1MoneyFinancial total for the category
.... total:adjudicationamounttype S1..*BackboneElementTotal adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit 0..*C4BBExplanationOfBenefitExplanation of Benefit resource
... id Ī£0..1stringLogical id of this artifact
... meta SĪ£1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies 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..1canonical(StructureDefinition)Profiles this resource claims to conform to

Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician|1.2.0
.... security Ī£0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Ī£0..*CodingTags 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..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..*IdentifierBusiness Identifier for the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SĪ£1..1CodeableConceptDescription of identifier
Binding: C4BB Claim Identifier Type (extensible)
.... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Ī£0..1stringThe value that is unique
Example General: 123456
.... period Ī£0..1PeriodTime period when id is/was valid for use
.... assigner Ī£0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SĪ£1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SĪ£1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: C4BB Professional And Non Clinician Claim SubType (required)
... use SĪ£1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SĪ£1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SĪ£1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start Ī£I0..1dateTimeStarting time with inclusive boundary
.... end Ī£I0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Ī£1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes (required)
.... reference S1..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee SI0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SI0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:billingnetworkcontractingstatus S0..1BackboneElementBilling provider contracting status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: billingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:performingnetworkcontractingstatus S0..1BackboneElementPerforming provider contracting status
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: performingnetworkcontractingstatus
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S1..1CodeableConceptType of information
Binding: C4BB Payer Provider Contracting Status (required)
..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1dateWhen it occurred
..... value[x] 0..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S1..1Reference(C4BB Organization)Data to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientaccountnumber
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
..... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S1..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£I1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SĪ£1..1booleanCoverage to be used for adjudication
.... coverage SĪ£1..1Reference(C4BB Coverage)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService SI1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 1..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... Slices for location[x] S1..1CodeableConceptPlace 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..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical 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 S0..*positiveIntApplicable note numbers
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:denialreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:allowedunits S0..1BackboneElementThe 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..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... adjudication 0..1See adjudication (ExplanationOfBenefit)Header-level adjudication
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (extensible)
..... amount Ī£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount Ī£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

.... unit 0..1CodeableConceptIndividual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

.... term 0..1CodeableConceptAnnual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

.... financial 0..*BackboneElementBenefit Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Max Binding: AllLanguages
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier.typeextensibleC4BBClaimIdentifierType
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredC4BBProfessionalAndNonClinicianClaimType
ExplanationOfBenefit.subTyperequiredC4BBProfessionalAndNonClinicianClaimSubType
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcareProviderTaxonomy
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.categoryextensiblePattern: billingnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.coderequiredC4BBPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.categoryextensiblePattern: performingnetworkcontractingstatus
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.coderequiredC4BBPayerProviderContractingStatus
ExplanationOfBenefit.supportingInfo:performingnetworkcontractingstatus.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
ExplanationOfBenefit.supportingInfo:servicefacility.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:servicefacility.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:patientaccountnumber.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typeexampleExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]exampleICD-10ProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredAMACPTCMSHCPCSProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.location[x]:locationCodeableConceptrequiredCMSPlaceofServiceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryrequiredC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:denialreason.categoryexamplePattern: denialreason
ExplanationOfBenefit.item.adjudication:denialreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.item.adjudication:allowedunits.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.addItem.subSiteexampleSurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ExplanationOfBenefit.total.categoryextensibleC4BBAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Max Binding: AllLanguages
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdPathDetailsRequirements
EOB-prof-careTeam-practitionerExplanationOfBenefit.careTeamProfessional 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) )
EOB-vision-item-productorserviceExplanationOfBenefit.item.productOrServiceVision EOB: Item productOrService not required in item.productOrService if and only if subType is vision.
: ExplanationOfBenefit.subType.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or ExplanationOfBenefit.item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()