Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last

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. CPCDS data element (190)

Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)

• pattern @ type

Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)

Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed

Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations

Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier

The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)

The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)

Date the claim was adjudicated (179)

Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider

The identifier assigned to the Billing Provider. (94)

If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)

Recipient reference (121)

Expected value is complete

careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values

The identifier assigned to the care team. (varies depending on the profile)

The functional role of a provider on a claim. (165)

Defines data elements not available in the base EOB resource

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

Identity of the payers responsible for the claim. (2, 141). All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier]

Line identification number that represents the number assigned in a source system for identification and processing. (36)

References number of the associated processNote entered

Indicates whether the claim was paid or denied. (91)

The date the claim was paid. (107)

Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181)

Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last

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. CPCDS data element (190)

Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)

• pattern @ type

Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)

Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed

Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations

Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier

The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)

The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)

Date the claim was adjudicated (179)

Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider

The identifier assigned to the Billing Provider. (94)

If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)

Recipient reference (121)

Expected value is complete

careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values

The identifier assigned to the care team. (varies depending on the profile)

The functional role of a provider on a claim. (165)

Defines data elements not available in the base EOB resource

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

Identity of the payers responsible for the claim. (2, 141). All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. An invariant is defined to enforce the following rule: Will have multiple occurrences on secondary / tertiary, etc. claims. Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'

Same as insurance.coverage.organization. Party responsible for reimbursing the provider. When focal = true, Coverage.payer--> Organization.identifier. When focal = false, EOB.insurance.coverage.display = [name of other carrier]

Line identification number that represents the number assigned in a source system for identification and processing. (36)

References number of the associated processNote entered

Indicates whether the claim was paid or denied. (91)

The date the claim was paid. (107)

Payment denial explanation to a member, typically goes on the EOB when the payment is denied or disallowed (181)

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

When the resource last changed - e.g. when the version changed.

Defines the date the Resource was created or updated, whichever comes last (163). Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

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. CPCDS data element (190)

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A unique identifier assigned to this explanation of benefit.

Allows EOBs to be distinguished and referenced.

Identifier assigned by a payer for a claim received from a provider or subscriber. It is not the same identifier as that assigned by a provider. (35)

• pattern @ type

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The purpose of this identifier.

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Identifier.system is always case sensitive.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

A unique identifier assigned to this explanation of benefit.

Allows EOBs to be distinguished and referenced.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The purpose of this identifier.

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Identifier.system is always case sensitive.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Claim processing status code (140). Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Specifies the type of claim. (e.g., inpatient institutional, outpatient institutional, physician, etc.) (16). Defines the Claims profiles. Values from Claim Type Codes are required; a data absent reason is not allowed

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes such as the US UB-04 bill type code.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

This element is required to understand the nature of the request for adjudication.

Expected value is claim. The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1). The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudication. Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier

The period for which charges are being submitted.

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The start of the period. The boundary is inclusive.

The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). (177)

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’). (178)

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

Date the claim was adjudicated (179)

Individual who created the claim, predetermination or preauthorization.

Some jurisdictions require the contact information for personnel completing claims.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Code of the payer responsible for the claim (2, 5). Same as insurance.coverage.organization. Party responsible for reimbursing the provider

The provider which is responsible for the claim, predetermination or preauthorization.

The identifier assigned to the Billing Provider. (94)

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

A code to indicate whether and for whom funds are to be reserved for future claims.

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

This field is only used for preauthorizations.

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

For workplace or other accidents it is common to relate separate claims arising from the same event.

If the current claim represents a claim that has been adjusted and was given a prior claim number, this field represents the prior claim number. If the current claim has been adjusted; i.e., replaced by or merged to another claim number, this data element represents that new number.(111, 112)

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Reference to a related claim.

For workplace or other accidents it is common to relate separate claims arising from the same event.

A code to convey how the claims are related.

Some insurers need a declaration of the type of relationship.

For example, prior claim or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains.

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

For example, Property/Casualty insurer claim number or Workers Compensation case number.

Prescription to support the dispensing of pharmacy, device or vision products.

Required to authorize the dispensing of controlled substances and devices.

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

The party to be reimbursed for cost of the products and services according to the terms of the policy.

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Type of Party to be reimbursed: Subscriber, provider, other.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient. (120)

Reference to the individual or organization to whom any payment will be made.

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Recipient reference (121)

A reference to a referral resource.

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

The referral resource which lists the date, practitioner, reason and other supporting information.

Facility where the services were provided.

Insurance adjudication can be dependant on where services were delivered.

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

To provide a link to the original adjudication request.

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

To provide a link to the original adjudication response.

The outcome of the claim, predetermination, or preauthorization processing.

To advise the requestor of an overall processing outcome.

Expected value is complete

A human readable description of the status of the adjudication.

Provided for user display.

Reference from the Insurer which is used in later communications which refers to this adjudication.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

On subsequent claims, the insurer may require the provider to quote this value.

This value is only present on preauthorization adjudications.

The members of the team who provided the products and services.

Common to identify the responsible and supporting practitioners.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A number to uniquely identify care team entries.

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

careTeam.sequence values uniquely identify careTeam members. They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc. Client app implementations should not assign any significance to the sequence values

Member of the team who provided the product or service.

Often a regulatory requirement to specify the responsible provider.

The identifier assigned to the care team. (varies depending on the profile)

The party who is billing and/or responsible for the claimed products or services.

When multiple parties are present it is required to distinguish the lead or responsible individual.

Responsible might not be required when there is only a single provider listed.

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

When multiple parties are present it is required to distinguish the roles performed by each member.

The functional role of a provider on a claim. (165)

The qualification of the practitioner which is applicable for this service.

Need to specify which qualification a provider is delivering the product or service under.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Defines data elements not available in the base EOB resource

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A number to uniquely identify supporting information entries.

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Client app implementations should look-up supportingInfo elements based on category values instead of sequence values

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

This may contain a category for the local bill type codes.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Required to identify the kind of additional information.

This may contain the local bill type codes such as the US UB-04 bill type code.

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

To convey the data content to be provided when the information is more than a simple code or period.

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

Provides the reason in the situation where a reason code is required in addition to the content.

Needed when the supporting information has both a date and amount/value and requires explanation.

For example: the reason for the additional stay, or why a tooth is missing.