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

This page is part of the CARIN Blue Button Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: C4BB ExplanationOfBenefit Inpatient Institutional

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional Version: 2.0.0
Active as of 2022-11-28 Computable Name: C4BBExplanationOfBenefitInpatientInstitutional

The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services.

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 and amount types of the claim are to be provided in EOB.total.  The in network or out of network payment status of the claim are to be provided in EOB.supportingInfo.
  • 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.
  • A CPT / HCPCS code may not be available on an inpatient institutional claim. 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 code is not available.
  • .diagnosis:  ICD-10 / ICD-9 diagnosis codes are defined as CodeableConcepts
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily indicate 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. 
  • .procedure:  ICD-10 / ICD-9 procedure codes are defined as CodeableConcepts
  • .procedure.sequence rule:  procedure.sequence values do not necessarily indicate any order in which the procedure occurred.  client app implementations should not assign any significance to the sequence values.  client app implementations should use the values of procedure.type to identify primary and secondary procedures
  • .supportingInfo[DRG]:  DRGs require the DRG system; i.e., MS-DRG / AP-DRG / APR-DRG, the DRG version and the code value
  • .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)
  • .adjudication[benefitpaymentstatus]:  in network or out of network payment status for the claim
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from C4BBExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... identifier S1..*IdentifierBusiness Identifier for the resource
... 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
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
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/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
.... end S0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created S1..1dateTimeResponse creation date
... provider 1..1Reference(C4BB Organization)Party responsible for the claim
... careTeam C0..*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
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo 1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... 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: admissionperiod
..... timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Open by type:$this
..... timingPeriod S1..1PeriodWhen it occurred
.... 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:typeofbill S0..1BackboneElementType of bill
..... 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 Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... 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 S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... 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 Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge 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: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... 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: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... 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
..... 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
..... 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... item C1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S0..*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 Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason 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: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (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
...... value S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... 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: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... 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: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason 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: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... 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 Total Category Discriminator Value Set (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 Value Set (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... meta SĪ£1..1MetaMetadata about the resource
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/C4BBIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
... 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: ClaimTypeCodes (required)
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
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
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/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
... 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
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end SĪ£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£1..1dateTimeResponse creation date
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*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
.... 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
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo S1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... 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 Value Set (extensible)
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... 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 Value Set (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: admissionperiod
..... Slices for timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S1..1PeriodWhen it occurred
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... 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 Value Set (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] S1..1dateWhen it occurred
.... supportingInfo:typeofbill S0..1BackboneElementType of bill
..... 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 Value Set (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: typeofbill
..... code S1..1CodeableConceptType of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... 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 Value Set (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: pointoforigin
..... code S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... 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 Value Set (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: admtype
..... code S1..1CodeableConceptType of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge status
..... 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 Value Set (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: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... 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 Value Set (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: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... 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 Value Set (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: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... 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 Value Set (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: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... 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
... item SC1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S0..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... 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
....... 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: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (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)
...... 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
....... 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 S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount Ī£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S0..1dateExpected date of payment
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... id Ī£0..1idLogical id of this artifact
... meta SĪ£1..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 Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies where the resource comes from
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... 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
... Slices for identifier S1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... 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 Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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/C4BBIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SĪ£1..1stringUnique Claim Identifier
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: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique 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 S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique 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/C4BBInstitutionalClaimSubType
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end SĪ£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£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)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 Value Set (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 SC0..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 Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)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 SC0..*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
.... 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 Institutional Care Team Role Value Set (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S1..*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 Value Set (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:admissionperiod S1..1BackboneElementAdmission Period
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: admissionperiod
....... 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.

..... Slices for timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S1..1PeriodWhen 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: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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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..1BackboneElementType of bill
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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..1BackboneElementPoint of origin for admission
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (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..1BackboneElementAdmission type
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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..1BackboneElementDischarge 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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:drg S0..1BackboneElementDiagnosis Related Group
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: drg
....... 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: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
..... 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: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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure S0..*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 S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£C1..*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 SC1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... 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 S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (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: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... 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 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
.... Slices for adjudication S0..*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 Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level 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 S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjustmentreason S0..*BackboneElementReason 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..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1idUnique 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: adjustmentreason
........ 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 Value Set (required)
...... 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..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1idUnique 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 S1..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
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
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 Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network 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
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: billingnetworkstatus
....... 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: C4BB Payer Provider Network Status Value Set (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 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: benefitpaymentstatus
....... 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: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level 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 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 1..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjustmentreason S0..*BackboneElementReason 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 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: adjustmentreason
....... 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 Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... 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 Total Category Discriminator Value Set (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 Value Set (required)
..... amount SĪ£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 Value Set (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S0..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 S0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... 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

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
ExplanationOfBenefit.supportingInfo:admissionperiod.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:admissionperiod.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:typeofbill.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:pointoforigin.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:discharge-status.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.supportingInfo:drg.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.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
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.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 12 elements (18 nested mandatory elements)
Must-Support: 62 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.timing[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.supportingInfo.value[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.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 C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... identifier S1..*IdentifierBusiness Identifier for the resource
... 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
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
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/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
.... end S0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created S1..1dateTimeResponse creation date
... provider 1..1Reference(C4BB Organization)Party responsible for the claim
... careTeam C0..*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
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo 1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... 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: admissionperiod
..... timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Open by type:$this
..... timingPeriod S1..1PeriodWhen it occurred
.... 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:typeofbill S0..1BackboneElementType of bill
..... 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 Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... 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 S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... 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 Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge 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: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... 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: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... 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
..... 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
..... 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... item C1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... Slices for adjudication S0..*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 Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason 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: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (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
...... value S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... 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: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... 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: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason 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: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... 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 Total Category Discriminator Value Set (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 Value Set (required)
..... amount S1..1MoneyFinancial total for the category
... payment
.... date S0..1dateExpected date of payment
... processNote
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... meta SĪ£1..1MetaMetadata about the resource
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Ī£0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Ī£0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


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/C4BBIdentifierType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
..... value SĪ£1..1stringUnique Claim Identifier
Example General: 123456
... 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: ClaimTypeCodes (required)
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
... subType S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
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/C4BBInstitutionalClaimSubType
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
... 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
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end SĪ£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£1..1dateTimeResponse creation date
... insurer SĪ£1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SĪ£1..1Reference(C4BB Organization)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)
.... reference S1..1IdentifierFile or case reference
... payee SC0..1BackboneElementRecipient of benefits payable
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S1..1CodeableConceptCategory of recipient
Binding: C4BB Payee Type Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)Recipient reference
... outcome SĪ£1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*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
.... 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
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)
... Slices for supportingInfo S1..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... 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 Value Set (extensible)
.... supportingInfo:admissionperiod S1..1BackboneElementAdmission Period
..... 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 Value Set (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: admissionperiod
..... Slices for timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S1..1PeriodWhen it occurred
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... 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 Value Set (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] S1..1dateWhen it occurred
.... supportingInfo:typeofbill S0..1BackboneElementType of bill
..... 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 Value Set (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: typeofbill
..... code S1..1CodeableConceptType of information
Binding: NUBC Type of Bill Codes Value Set (required)
.... supportingInfo:pointoforigin S0..1BackboneElementPoint of origin for admission
..... 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 Value Set (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: pointoforigin
..... code S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (required)
.... supportingInfo:admtype S0..1BackboneElementAdmission type
..... 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 Value Set (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: admtype
..... code S1..1CodeableConceptType of information
Binding: NUBC Priority (Type) of Admission or Visit Value Set (required)
.... supportingInfo:discharge-status S0..1BackboneElementDischarge status
..... 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 Value Set (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: discharge-status
..... code S1..1CodeableConceptType of information
Binding: NUBC Patient Discharge Status Codes Value Set (required)
.... supportingInfo:drg S0..1BackboneElementDiagnosis Related Group
..... 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 Value Set (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: drg
..... code S1..1CodeableConceptType of information
Binding: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... 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 Value Set (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: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... 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 Value Set (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: patientaccountnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
... procedure S0..*BackboneElementClinical procedures performed
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
... insurance SĪ£C1..*BackboneElementPatient insurance information
.... 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
... item SC1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... revenue S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S0..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level adjudication type and amount
...... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... 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
....... 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: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (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)
...... 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
....... 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 S1..1decimalNon-monitary value
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network status
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: billingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
.... adjudication:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: benefitpaymentstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Benefit Payment Status Value Set (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:adjustmentreason S0..*BackboneElementReason codes used to interpret the Non-Covered Amount (92)
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... 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: adjustmentreason
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes Value Set (required)
... Slices for total SĪ£1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SĪ£1..1CodeableConceptType of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)
..... amount Ī£1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SĪ£1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Ī£1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount SĪ£1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
.... date S0..1dateExpected date of payment
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Ī£0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... text S0..1stringNote explanatory text

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-inst-pointoforiginerrorExplanationOfBenefitWhere Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
: (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code = '4').exists() and supportingInfo.where(code.coding.system='AHANUBCPointOfOriginForAdmissionOrVisitNonnewborn').exists()).not() and (supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PriorityTypeOfAdmitOrVisit' and code.coding.code != '4').exists() and supportingInfo.where(code.coding.system = 'https://www.nubc.org/CodeSystem/PointOfOriginNewborn').exists() ).not()
EOB-institutional-inpatient-meta-profile-versionerrorExplanationOfBenefitInstitutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
: meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Inpatient-Institutional|2.0.'))
EOB-institutional-item-or-header-adjudicationerrorExplanationOfBenefitInstitutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
: adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists() != item.adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists()
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-institutional-inpatient-meta-profile-version: Institutional Inpatient EOB: meta.profile with canonical and major.minor. version required.
EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem.
EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both
... id Ī£0..1idLogical id of this artifact
... meta SĪ£1..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 Ī£0..1idVersion specific identifier
.... lastUpdated SĪ£1..1instantWhen the resource version last changed
.... source Ī£0..1uriIdentifies where the resource comes from
.... profile Ī£1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... 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
... Slices for identifier S1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... id 0..1stringUnique id for inter-element referencing
..... 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 Ī£1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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/C4BBIdentifierType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: uc
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Ī£0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SĪ£1..1stringUnique Claim Identifier
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: ClaimTypeCodes (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique 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 S1..1CodeableConceptMore granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique 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/C4BBInstitutionalClaimSubType
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: inpatient
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SĪ£C1..1dateTimeStarting time with inclusive boundary
.... end SĪ£C0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created SĪ£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)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 Value Set (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 SC0..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 Value Set (required)
.... party S0..1Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)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 SC0..*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
.... 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 Institutional Care Team Role Value Set (required)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... Slices for supportingInfo S1..*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 Value Set (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:admissionperiod S1..1BackboneElementAdmission Period
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: admissionperiod
....... 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.

..... Slices for timing[x] 1..1PeriodWhen it occurred
Slice: Unordered, Closed by type:$this
...... timing[x]:timingPeriod S1..1PeriodWhen 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: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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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..1BackboneElementType of bill
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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..1BackboneElementPoint of origin for admission
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 S1..1CodeableConceptType of information
Binding: NUBC Point Of Origin Value Set (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..1BackboneElementAdmission type
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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..1BackboneElementDischarge 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (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:drg S0..1BackboneElementDiagnosis Related Group
..... 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: drg
....... 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: MS-DRGs - AP-DRGs - APR-DRGs Value Set (extensible)
..... 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: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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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 Value Set (extensible)
Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Inpatient Institutional Diagnosis Type Value Set (required)
.... onAdmission S0..1CodeableConceptPresent on admission
Binding: NUBC Present On Admission Indicator Codes Value Set (required)
.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure S0..*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 S1..1CodeableConceptCategory of Procedure
Binding: C4BB Claim Procedure Type Value Set (required)
.... date S0..1dateTimeWhen the procedure was performed
.... procedure[x] S1..1CodeableConceptSpecific clinical procedure
Binding: Procedure Codes - International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - ICD-10 Procedure Value Set (required)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance SĪ£C1..*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 SC1..*BackboneElementProduct or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
.... 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 S1..1CodeableConceptRevenue or cost center code
Binding: NUBC Revenue Codes Value Set (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: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... 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 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
.... Slices for adjudication S0..*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 Value Set (extensible)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S0..*BackboneElementLine level 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 S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjustmentreason S0..*BackboneElementReason 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..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1idUnique 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: adjustmentreason
........ 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 Value Set (required)
...... 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..1idUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1idUnique 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 S1..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
... Slices for adjudication S1..*BackboneElementHeader-level adjudication
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 Value Set (extensible)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:billingnetworkstatus S0..1BackboneElementBilling provider network 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
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: billingnetworkstatus
....... 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: C4BB Payer Provider Network Status Value Set (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 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: benefitpaymentstatus
....... 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: C4BB Payer Benefit Payment Status Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjudicationamounttype S0..*BackboneElementClaim level 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 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 1..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjustmentreason S0..*BackboneElementReason 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 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1idUnique 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: adjustmentreason
....... 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 Value Set (required)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
... 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 Total Category Discriminator Value Set (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 Value Set (required)
..... amount SĪ£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 Value Set (required)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date S0..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 S0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... 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

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.meta.securityextensibleAll Security Labels
ExplanationOfBenefit.meta.tagexampleCommonTags
ExplanationOfBenefit.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredPattern: institutional
ExplanationOfBenefit.subTyperequiredPattern: inpatient
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequestedexampleFunds Reservation Codes
ExplanationOfBenefit.fundsReserveexampleFunds Reservation Codes
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimInstitutionalCareTeamRole
ExplanationOfBenefit.careTeam.qualificationexampleExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:admissionperiod.categoryextensiblePattern: admissionperiod
ExplanationOfBenefit.supportingInfo:admissionperiod.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:admissionperiod.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.codeexampleExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:typeofbill.categoryextensiblePattern: typeofbill
ExplanationOfBenefit.supportingInfo:typeofbill.coderequiredAHANUBCTypeOfBill
ExplanationOfBenefit.supportingInfo:typeofbill.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:pointoforigin.categoryextensiblePattern: pointoforigin
ExplanationOfBenefit.supportingInfo:pointoforigin.coderequiredAHANUBCPointOfOriginForAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:pointoforigin.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:admtype.categoryextensiblePattern: admtype
ExplanationOfBenefit.supportingInfo:admtype.coderequiredAHANUBCPriorityTypeOfAdmissionOrVisit
ExplanationOfBenefit.supportingInfo:admtype.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:discharge-status.categoryextensiblePattern: discharge-status
ExplanationOfBenefit.supportingInfo:discharge-status.coderequiredAHANUBCPatientDischargeStatus
ExplanationOfBenefit.supportingInfo:discharge-status.reasonexampleMissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:drg.categoryextensiblePattern: drg
ExplanationOfBenefit.supportingInfo:drg.codeextensibleCMSMS3MAPAPRDRG
ExplanationOfBenefit.supportingInfo:drg.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.typerequiredC4BBClaimInpatientInstitutionalDiagnosisType
ExplanationOfBenefit.diagnosis.onAdmissionrequiredAHANUBCPresentOnAdmission (a valid code from NUBC Present On Admission Indicator Code System)
ExplanationOfBenefit.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.typerequiredC4BBClaimProcedureType (a valid code from C4BB Claim Procedure Type Code System)
ExplanationOfBenefit.procedure.procedure[x]requiredCMSICD910PCSProcedureCodes
ExplanationOfBenefit.accident.typeextensibleActIncidentCode
ExplanationOfBenefit.item.revenuerequiredAHANUBCRevenueCodes
ExplanationOfBenefit.item.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.item.productOrServicerequiredC4BBEOBInstitutionalProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.programCodeexampleExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySiteexampleOralSiteCodes
ExplanationOfBenefit.item.subSiteexampleSurfaceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
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.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.adjudication:adjudicationamounttype.reasonexampleAdjudicationReasonCodes
ExplanationOfBenefit.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.total.categoryextensibleC4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCodeexampleForm Codes
ExplanationOfBenefit.processNote.typerequiredNoteType
ExplanationOfBenefit.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.categoryexampleBenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.networkexampleNetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unitexampleUnitTypeCodes
ExplanationOfBenefit.benefitBalance.termexampleBenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.typeexampleBenefitTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
EOB-inst-careTeam-organizationerrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to an organization
: ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-inst-careTeam-practitionererrorExplanationOfBenefit.careTeamInstitutional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('attending' | 'primary' | 'referring' | 'supervising')).exists()).exists().provider.all(resolve() is Practitioner) )
adjudication-has-amount-type-sliceerrorExplanationOfBenefit.itemIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())

This structure is derived from C4BBExplanationOfBenefit

Summary

Mandatory: 12 elements (18 nested mandatory elements)
Must-Support: 62 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.timing[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.supportingInfo.value[x] is sliced based on the value of type:$this
  • The element ExplanationOfBenefit.item.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.adjudication is sliced based on the value of pattern:category
  • The element ExplanationOfBenefit.total is sliced based on the value of pattern:category

 

Other representations of profile: CSV, Excel, Schematron