CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1

This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: STU 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 Outpatient Institutional

Defining URL:http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional
Version:1.0.0
Name:C4BBExplanationOfBenefitOutpatientInstitutional
Title:C4BB ExplanationOfBenefit Outpatient Institutional
Status:Active as of 2020-11-23T17:26:16+00:00
Definition:

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services.

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-Outpatient-Institutional

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 and amount types are to be provided in EOB.item.  If a Payer does not have line item amounts, provide the claim amounts and amount types in the EOB header data elements.  Total amounts, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total.
  • The determination of inpatient vs. outpatient institutional claims is defined by the Type of Bill. The NUBC manual defines which TOBs are inpatient vs outpatient.</p> .diagnosis:  ICD-10 / ICD-9 diagnosis codes are defined as CodeableConcepts  
  • .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. 
  • .item.productOrService:  CPT / HCPCS procedure codes are defined as CodeableConcepts
  • .adjudication.amount (populate only if item.adjudication is not available):  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.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)
  • .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)
  • .total[inoutnetwork]:  in network or out of network payment status for the claim
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 3 elements (9 nested mandatory elements)
Must-Support: 35 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.item.serviced[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category (Closed)
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category (Closed)
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication at the item or header level, but not both
... type 1..1CodeableConceptCategory or discipline
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://terminology.hl7.org/CodeSystem/claim-type
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
... created S1..1dateTimeResponse creation date
... provider 1..1Reference(C4BB Organization)Party responsible for the claim
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: US Core Provider Speciality (NUCC) (required)
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:billingnetworkcontractingstatus 0..1BackboneElementSupporting information
..... 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:clmrecvddate 0..1BackboneElementSupporting information
..... 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:typeofbill 0..1BackboneElementSupporting information
..... 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: typeofbill
..... code S1..1CodeableConceptType of information
Binding: NUBC Type of Bill Codes (required)
.... supportingInfo:pointoforigin 0..1BackboneElementSupporting information
..... 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: pointoforigin
..... code S0..1CodeableConceptType of information
Binding: NUBC Point Of Origin (required)
.... supportingInfo:admtype 0..1BackboneElementSupporting information
..... 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: admtype
..... code S1..1CodeableConceptType of information
Binding: NUBC Priority (Type) of Admission or Visit (required)
.... supportingInfo:discharge-status 0..1BackboneElementSupporting information
..... 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: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes (required)
... diagnosis 1..*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 Outpatient Institutional Diagnosis Type (required)
... item 0..*BackboneElementProduct or service provided
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Codes (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Modifier Codes (required)
.... serviced[x] 0..1(Slice Definition)Date or dates of service or product delivery
Slice: Unordered, Open by type:$this
.... servicedDate S0..1dateDate or dates of service or product delivery
.... quantity S0..1SimpleQuantityCount of products or services
.... adjudication SI0..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by pattern:category
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype S0..*BackboneElementAdjudication details
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
...... amount S0..1MoneyMonetary amount
..... adjudication:denialreason S0..*BackboneElementAdjudication details
...... 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:allowedunits S0..1BackboneElementAdjudication details
...... 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
...... value S0..1decimalNon-monitary value
... adjudication SI0..*(Slice Definition)Header-level adjudication
Slice: Unordered, Closed by pattern:category
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator (required)
.... adjudication:adjudicationamounttype 0..*BackboneElementHeader-level adjudication
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount S1..1MoneyMonetary amount
.... adjudication:denialreason 0..*BackboneElementHeader-level adjudication
..... 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)
... total 1..*(Slice Definition)Adjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator (extensible)
..... amount 1..1MoneyFinancial total for the category
.... total:adjudicationamounttype 1..*BackboneElementAdjudication totals
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication (required)
..... amount S1..1MoneyFinancial total for the category
.... total:inoutnetwork 0..1BackboneElementAdjudication totals
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Payer Benefit Payment Status (required)
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format
</
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit I0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication at the item or header level, but not both
... id Σ0..1stringLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*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 ?!Σ0..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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SΣ1..1CodeableConceptDescription of identifier
Binding: C4BB Claim Identifier Type (extensible)
.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (required)
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://terminology.hl7.org/CodeSystem/claim-type
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: institutional
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ0..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣI0..1dateTimeStarting time with inclusive boundary
.... end ΣI0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SΣ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization)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 ?!Σ0..*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 S0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type (required)
.... party S1..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 SΣ1..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-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
EOB-careteam-qualification: Care Team Performing physician's qualifications are from US-Core-Provider-Specialty Value Set
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*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 Institutional Care Team Role (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: US Core Provider Speciality (NUCC) (required)
... supportingInfo S0..*(Slice Definition)Supporting 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 ?!Σ0..*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..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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:clmrecvddate S0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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:typeofbill S0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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: typeofbill
....... 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: NUBC Type of Bill Codes (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:pointoforigin S0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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: pointoforigin
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code S0..1CodeableConceptType of information
Binding: NUBC Point Of Origin (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:admtype S0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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: admtype
....... 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: NUBC Priority (Type) of Admission or Visit (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:discharge-status S0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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: discharge-status
....... 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: NUBC Patient Discharge Status Codes (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.

... diagnosis 1..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*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 Outpatient Institutional 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 ?!Σ0..*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 SΣI1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣ1..1booleanCoverage to be used for adjudication
.... coverage SΣ1..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 ?!Σ0..*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 S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*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 S0..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes (required)
.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Codes (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Current Procedural Terminology (CPT) - Healthcare Common Procedure Coding System (HCPCS) level II alphanumeric codes - Procedure Modifier Codes (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1(Slice Definition)Date or dates of service or product delivery
Slice: Unordered, Closed by type:$this
..... serviced[x]:servicedDate S0..1dateDate or dates of service or product delivery
.... 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 S0..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
.... adjudication SI0..*(Slice Definition)Adjudication details
Slice: Unordered, Closed by pattern:category
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*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 S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*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 S0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:denialreason S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*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:allowedunits S0..1BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*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 S0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided