CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
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 Professional NonClinician

Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Professional-NonClinician Version: 2.0.0
Active as of 2022-11-28 Computable Name: C4BBExplanationOfBenefitProfessionalNonClinician

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional and vision services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.

Notes on Fields

  • The EOB FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • CPCDS data elements are mapped to EOB header or EOB.item data elements in alignment with claims submission standards.  Line item amounts, amount types and the in network or out of network payment status of the line are to be provided in EOB.item.  Total amounts, amount types and the in network or out of network payment status of the claim are to be provided in EOB.total If there is a mix of lines paid in network and out of network on a claim, the value of C4BB Payer Benefit Payment Status is ‘Other’
  • .diagnosis.sequence rule:  diagnosis.sequence values do not necessarily 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. 
  • .diagnosis.sequence:  sequentially numbers all diagnoses at the header-level. Item-level are referenced from an item using this sequence number
  • .supportingInfo[servicefacility]:  Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Rendering Provider.
  • .item. diagnosisSequence:  References the sequence number of the associated diagnosis entered above
  • .item.productOrService:   CPT / HCPCS procedure codes are defined as CodeableConcepts: A revenue code will not be available on a professional / non-clinician claim . The cardinality of the HL7 base EOB Resource for .item.revenue is 1..1 if .item is provided. Since item.productOrService is required it means that .item.revenue must be populated. Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason for item.revenue.
  • A CPT / HCPCS code may not be available on a professional nonclinician vision claim (vision only). The cardinality of the HL7 base EOB Resource for item.productOrService is 1..1 if .item is provided.  Since .item.revenue is required it means that item.productOrService must be populated.  Since the profile is not able to relax the cardinality of the resource, it is recommended payers provide a data absent reason when a CPT / HCPCS or code is not available.
  • Every supportingInfo repetitions with a Transportation Services Category code need to be associated with at least one line item by referencing supportingInfo.sequence through .item.informationSequence.
  • item.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the line
  • .item.adjudication.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • .total.amount:  Eligible amount = submitted amount - the noncovered amount - discount.  The subscriber pays the member liability = deductible + coinsurance + copay + noncovered.  (part of the member liability may have already been paid to the provider as paidbypatient). The eligible amount - the member liability is the payment amount to the provider (paidtoprovider) or the subscriber (paidtopatient)
  • The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

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-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
EOB-prof-all-transportation-supportinginfo-linked-to-line: Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
... type 1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... careTeam C0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... role 1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: clmrecvddate
..... timing[x] S1..1dateWhen it occurred
.... supportingInfo:servicefacility S0..1BackboneElementService facility
..... category S1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: servicefacility
..... value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Open by type:$this
..... valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$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:$this
..... valueString S1..1stringData to be provided
.... supportingInfo:patientweight S0..*BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientweight
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1QuantityData to be provided
Slice: Unordered, Open by type:$this
..... valueQuantity 1..1QuantityData to be provided
...... value 1..1decimalNumerical value (with implicit precision)
...... unit 0..1stringUnit representation
Required Pattern: [lb_av]
...... system 0..1uriSystem that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:ambulancetransportreason S0..*BackboneElementSupporting information
..... 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: ambulancetransportreason
..... code 0..0
..... timing[x] 0..0
..... reason 1..1CodingExplanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S0..*BackboneElementSupporting information
..... 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: transportationdistance
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1QuantityData to be provided
Slice: Unordered, Open by type:$this
..... valueQuantity 1..1QuantityData to be provided
...... value 1..1decimalNumerical value (with implicit precision)
...... unit 0..1stringUnit representation
Required Pattern: [mi_i]
...... system 0..1uriSystem that defines coded unit form
Required Pattern: http://unitsofmeasure.org
.... supportingInfo:roudtrippurpose S0..*BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: roudtrippurpose
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString 1..1stringData to be provided
.... supportingInfo:stretcherpurpose S0..*BackboneElementSupporting information
..... 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: stretcherpurpose
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString 1..1stringData to be provided
.... supportingInfo:pickuplocation S0..*BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: pickuplocation
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString 1..1stringData to be provided
.... supportingInfo:dropofflocation S0..*BackboneElementSupporting information
..... 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: dropofflocation
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1stringData to be provided
Slice: Unordered, Open by type:$this
..... valueString 1..1stringData to be provided
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... item
.... productOrService SC1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1date, PeriodDate or dates of service or product delivery
.... location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... category 1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:adjustmentreason S0..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: adjustmentreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes 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: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
... Slices for adjudication S0..*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 networking 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:renderingnetworkstatus S0..1BackboneElementRendering provider networking 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: renderingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status 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 Adjudication 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ExplanationOfBenefit.typerequiredC4BBProfessionalAndNonClinicianClaimType
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ExplanationOfBenefit.supportingInfo:ambulancetransportreason.reasonrequiredC4BBAmbulanceTransportReasonCodes (a valid code from X12 Ambulance Transport Reason Codes Code System)
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
ExplanationOfBenefit.item.productOrServicerequiredAMACPTCMSHCPCSProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.locationCodeableConceptrequiredCMSPlaceofServiceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.total.categoryextensibleC4BBAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-all-transportation-supportinginfo-linked-to-lineerrorExplanationOfBenefitProfessional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-professional-nonclinician-meta-profile-versionerrorExplanationOfBenefitProfessional and Nonclinician 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-Professional-NonClinician|2.0.'))
EOB-vision-item-productorserviceerrorExplanationOfBenefit.item.productOrServiceVision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
: ExplanationOfBenefit.type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or ExplanationOfBenefit.item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
EOB-prof-all-transportation-supportinginfo-linked-to-line: Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
... meta SΣ1..1MetaMetadata about the resource
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... identifier:All Slices Content/Rules for all slices
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... identifier:uniqueclaimid S1..1IdentifierUnique Claim Identifier
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..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 SΣ1..1stringUnique Claim Identifier
Example General: 123456
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..1PeriodRelevant time frame for the claim
.... start SΣC1..1dateTimeStarting time with inclusive boundary
... created Σ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... related S0..*BackboneElementPrior or corollary claims
.... modifierExtension ?!Σ0..*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 ?!Σ0..*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 SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... careTeam SC0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(C4BB Organization | C4BB Practitioner)Practitioner or organization
.... role S1..1CodeableConceptFunction within the team
Binding: C4BB Claim Professional And Non Clinician Care Team Role Value Set (required)
.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by pattern:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
.... supportingInfo:clmrecvddate S0..1BackboneElementClaim received date
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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:servicefacility S0..1BackboneElementService facility
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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: servicefacility
..... Slices for value[x] 1..1Reference(Resource)Data to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueReference S1..1Reference(C4BB Organization)Data to be provided
.... supportingInfo:medicalrecordnumber S0..1BackboneElementMedical record number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: medicalrecordnumber
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientaccountnumber S0..1BackboneElementPatient account number
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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:$this
...... value[x]:valueString S1..1stringData to be provided
.... supportingInfo:patientweight S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientweight
..... Slices for value[x] 1..1QuantityData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueQuantity 1..1QuantityData to be provided
....... value Σ1..1decimalNumerical value (with implicit precision)
....... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

.... supportingInfo:ambulancetransportreason S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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: ambulancetransportreason
..... reason 1..1CodingExplanation for the information
Binding: C4BB Ambulance Transport Reasons Value Set (required)
.... supportingInfo:transportationdistance S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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: transportationdistance
..... Slices for value[x] 1..1QuantityData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueQuantity 1..1QuantityData to be provided
....... value Σ1..1decimalNumerical value (with implicit precision)
....... comparator ?!Σ0..1code< | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.

.... supportingInfo:roudtrippurpose S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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: roudtrippurpose
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString 1..1stringData to be provided
.... supportingInfo:stretcherpurpose S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: stretcherpurpose
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString 1..1stringData to be provided
.... supportingInfo:pickuplocation S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type 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: pickuplocation
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString 1..1stringData to be provided
.... supportingInfo:dropofflocation S0..*BackboneElementSupporting information
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dropofflocation
..... Slices for value[x] 1..1stringData to be provided
Slice: Unordered, Closed by type:$this
...... value[x]:valueString 1..1stringData to be provided
... diagnosis S1..*BackboneElementPertinent diagnosis information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)
.... type S1..1CodeableConceptTiming or nature of the diagnosis
Binding: C4BB Claim Professional And Non Clinician Diagnosis Type Value Set (required)
... insurance SΣC1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal SΣ1..1booleanCoverage to be used for adjudication
.... coverage SΣ1..1Reference(C4BB Coverage)Insurance information
... item S1..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... productOrService SC1..1CodeableConceptBilling, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS Value Set (required)
EOB-vision-item-productorservice: Vision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)
.... serviced[x] 1..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... Slices for location[x] S1..1CodeableConceptPlace of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... location[x]:locationCodeableConcept 1..1CodeableConceptPlace of service or where product was supplied
Binding: CMS Place of Service Codes (POS) Value Set (required)
.... quantity 0..1SimpleQuantityCount of products or services
.... noteNumber S0..*positiveIntApplicable note numbers
.... Slices for adjudication S2..*BackboneElementAdjudication details
Slice: Unordered, Open by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
..... adjudication:adjudicationamounttype S1..*BackboneElementAmounts
...... modifierExtension ?!Σ0..*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..1BackboneElementReason codes used to interpret the Non-Covered Amount (92)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... 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:benefitpaymentstatus S1..1BackboneElementIndicates the in network or out of network payment status of the claim. (142)
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... 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: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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Open by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*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 networking status
..... modifierExtension ?!Σ0..*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:renderingnetworkstatus S0..1BackboneElementRendering provider networking status
..... modifierExtension ?!Σ0..*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: renderingnetworkstatus
..... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: C4BB Payer Provider Network Status Value Set (required)
... Slices for total SΣ1..*BackboneElementAdjudication totals
Slice: Unordered, Open by pattern:category
.... total:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category SΣ1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (extensible)
..... amount Σ1..1MoneyFinancial total for the category
.... total:adjudicationamounttype SΣ1..*BackboneElementTotal adjudication type and amount
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category Σ1..1CodeableConceptType of adjudication information
Binding: C4BB Adjudication Value Set (required)
..... amount Σ1..1MoneyFinancial total for the category
... payment S0..1BackboneElementPayment Details
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptPartial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)
... processNote S0..*BackboneElementNote concerning adjudication
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ExplanationOfBenefit.identifier.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.userequiredIdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.typeextensiblePattern: uc
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
ExplanationOfBenefit.typerequiredC4BBProfessionalAndNonClinicianClaimType
ExplanationOfBenefit.userequiredPattern: claim
ExplanationOfBenefit.related.relationshiprequiredC4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.typerequiredC4BBPayeeType
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
ExplanationOfBenefit.careTeam.rolerequiredC4BBClaimProfessionalAndNonClinicianCareTeamRole
ExplanationOfBenefit.careTeam.qualificationrequiredHealthcare Provider Taxonomy (a valid code from http://nucc.org/provider-taxonomy)
ExplanationOfBenefit.supportingInfo.categoryextensibleC4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:clmrecvddate.categoryextensiblePattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:servicefacility.categoryextensiblePattern: servicefacility
ExplanationOfBenefit.supportingInfo:medicalrecordnumber.categoryextensiblePattern: medicalrecordnumber
ExplanationOfBenefit.supportingInfo:patientaccountnumber.categoryextensiblePattern: patientaccountnumber
ExplanationOfBenefit.supportingInfo:patientweight.categoryextensiblePattern: patientweight
ExplanationOfBenefit.supportingInfo:patientweight.value[x]:valueQuantity.comparatorrequiredQuantityComparator
ExplanationOfBenefit.supportingInfo:ambulancetransportreason.categoryextensiblePattern: ambulancetransportreason
ExplanationOfBenefit.supportingInfo:ambulancetransportreason.reasonrequiredC4BBAmbulanceTransportReasonCodes (a valid code from X12 Ambulance Transport Reason Codes Code System)
ExplanationOfBenefit.supportingInfo:transportationdistance.categoryextensiblePattern: transportationdistance
ExplanationOfBenefit.supportingInfo:transportationdistance.value[x]:valueQuantity.comparatorrequiredQuantityComparator
ExplanationOfBenefit.supportingInfo:roudtrippurpose.categoryextensiblePattern: roudtrippurpose
ExplanationOfBenefit.supportingInfo:stretcherpurpose.categoryextensiblePattern: stretcherpurpose
ExplanationOfBenefit.supportingInfo:pickuplocation.categoryextensiblePattern: pickuplocation
ExplanationOfBenefit.supportingInfo:dropofflocation.categoryextensiblePattern: dropofflocation
ExplanationOfBenefit.diagnosis.diagnosis[x]requiredCDCICD910CMDiagnosisCodes
ExplanationOfBenefit.diagnosis.typerequiredC4BBClaimProfessionalAndNonClinicianDiagnosisType
ExplanationOfBenefit.item.productOrServicerequiredAMACPTCMSHCPCSProcedureCodes
ExplanationOfBenefit.item.modifierrequiredAMACPTCMSHCPCSModifiers
ExplanationOfBenefit.item.location[x]exampleExampleServicePlaceCodes
ExplanationOfBenefit.item.location[x]:locationCodeableConceptrequiredCMSPlaceofServiceCodes
ExplanationOfBenefit.item.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjustmentreason.categoryexamplePattern: adjustmentreason
ExplanationOfBenefit.item.adjudication:adjustmentreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.categoryexamplePattern: benefitpaymentstatus
ExplanationOfBenefit.item.adjudication:benefitpaymentstatus.reasonrequiredC4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
ExplanationOfBenefit.adjudication.categoryextensibleC4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.categoryexamplePattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.categoryexamplePattern: renderingnetworkstatus
ExplanationOfBenefit.adjudication:renderingnetworkstatus.reasonrequiredC4BBPayerProviderNetworkStatus
ExplanationOfBenefit.total.categoryextensibleC4BBAdjudication
ExplanationOfBenefit.total:adjudicationamounttype.categoryrequiredC4BBAdjudication
ExplanationOfBenefit.payment.typerequiredC4BBPayerClaimPaymentStatusCode

Constraints

IdGradePath(s)DetailsRequirements
EOB-prof-all-transportation-supportinginfo-linked-to-lineerrorExplanationOfBenefitProfessional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
: supportingInfo.where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBTransportationServiceCategories')).sequence.subsetOf(%context.item.informationSequence)
EOB-prof-careTeam-practitionererrorExplanationOfBenefit.careTeamProfessional EOB: Careteam roles refer to a practitioner
: ( role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising')).exists()).exists() implies role.where(coding.where(code in ('rendering' | 'primary' | 'referring' | 'supervising' )).exists()).exists().provider.all(resolve() is Practitioner) )
EOB-professional-nonclinician-meta-profile-versionerrorExplanationOfBenefitProfessional and Nonclinician 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-Professional-NonClinician|2.0.'))
EOB-vision-item-productorserviceerrorExplanationOfBenefit.item.productOrServiceVision EOB: Item productOrService not required in item.productOrService if and only if type is vision.
: ExplanationOfBenefit.type.coding.where(code = 'vision' and system='http://terminology.hl7.org/CodeSystem/claim-type').exists() or ExplanationOfBenefit.item.productOrService.coding.where(code = 'not-applicable' and system = 'http://terminology.hl7.org/CodeSystem/data-absent-reason').exists().not()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*C4BBExplanationOfBenefitExplanation of Benefit resource
EOB-professional-nonclinician-meta-profile-version: Professional and Nonclinician EOB: meta.profile with canonical and major.minor. version required.
EOB-prof-all-transportation-supportinginfo-linked-to-line: Professional EOB: SupportingInfo repetitions with with transportation category code must be referred to by one or more repetitions of item.informationSequence
... id Σ0..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): 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 1..*IdentifierBusiness Identifier for the resource
Slice: Unordered, Open by pattern:type
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..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.

..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... 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 ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..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 Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ1..1stringUnique Claim Identifier
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: C4BB Professional And Non Clinician Claim Type Value Set (required)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

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


Required Pattern: claim
... patient SΣ1..1Reference(C4BB Patient)The recipient of the products and services
... billablePeriod SΣ1..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 SΣC1..1dateTimeStarting time with inclusive boundary
.... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Σ1..1dateTimeResponse creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(C4BB Organization)Party responsible for reimbursement
... provider SΣ1..1Reference(C4BB Organization | C4BB Practitioner)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

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

... related S0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship S1..1CodeableConceptHow the reference claim is related
Binding: C4BB Related Claim Relationship Codes 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 ?!Σ0..*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 SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod 0..*PeriodPreauthorization in-effect period
... careTeam SC0..*BackboneElementCare Team members
EOB-prof-careTeam-practitioner: Professional EOB: Careteam roles refer to a practitioner
....