C4BB-ExplanationOfBenefit-Outpatient-Institutional vs C4BB-ExplanationOfBenefit-Outpatient-Institutional

Logical id of this artifact

0..1

Logical id of this artifact

Meta

Metadata about the resource

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

Slices for extension

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

versionId

0..1

Version specific identifier

0..1

Version specific identifier

lastUpdated

SΣ

1..1

instant

When the resource version last changed

SΣ

1..1

instant

When the resource version last changed

source

0..1

Identifies where the resource comes from

0..1

canonical(StructureDefinition)

Identifies where the resource comes from

Slices for profile

1..*

Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this

1..*

canonical(StructureDefinition)

Profiles this resource claims to conform to

security

0..*

Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.

0..*

Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.

tag

0..*

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

0..*

Tags 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

?!Σ

0..1

A set of rules under which this content was created

?!Σ

0..1

A set of rules under which this content was created

language

0..1

Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

0..1

Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

text

0..1

Narrative

Text summary of the resource, for human interpretation

0..1

Narrative

Text summary of the resource, for human interpretation

contained

0..*

Resource

Contained, inline Resources

0..*

Resource

Contained, inline Resources

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

0..*

Extensions that cannot be ignored

0..*

Extensions that cannot be ignored

identifier

1..*

Business Identifier for the resource

1..*

Business Identifier for the resource
Slice: Unordered, Open by pattern:type

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

Slices for extension

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

use

?!Σ

0..1

usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

?!Σ

0..1

usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

type

SΣ

1..1

Description of identifier
Binding: C4BBClaimIdentifierType (extensible)

0..1

Description 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.

Elements differ in comments: 'Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)' vs '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.'
Elements differ in definition for mustSupport: 'true' vs 'false'
Element minimum cardinalities differ: '1' vs '0'

system

0..1

The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient

0..1

The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient

value

0..1

The value that is unique
Example General: 123456

0..1

The value that is unique
Example General: 123456

period

0..1

Time period when id is/was valid for use

0..1

Time period when id is/was valid for use

assigner

0..1

Reference(Organization)

Organization that issued id (may be just text)

0..1

Reference(Organization)

Organization that issued id (may be just text)

status

?!SΣ

1..1

active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

?!SΣ

1..1

active | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

type

SΣ

1..1

Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"institutional"}]}

SΣ

1..1

Category or discipline
Binding: ClaimTypeCodes (required)
Required Pattern: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"institutional"}]}

subType

1..1

More granular claim type
Binding: C4BBInstitutionalClaimSubType (required)
Required Pattern: {"coding":[{"system":"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType","code":"outpatient"}]}

1..1

More granular claim type
Binding: C4BB Institutional Claim SubType Value Set (required)
Required Pattern: {"coding":[{"system":"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType","code":"outpatient"}]}

use

SΣ

1..1

claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

Required Pattern: claim

SΣ

1..1

claim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.

Required Pattern: claim

patient

SΣ

1..1

Reference(C4BB Patient)

The recipient of the products and services

SΣ

1..1

Reference(C4BB Patient)

The recipient of the products and services

billablePeriod

SΣ

0..1

Relevant time frame for the claim

SΣ

1..1

Relevant time frame for the claim

Element minimum cardinalities differ: '0' vs '1'

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

Slices for extension

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

start

ΣC

0..1

Starting time with inclusive boundary

SΣC

1..1

Starting time with inclusive boundary

Elements differ in definition for mustSupport: 'false' vs 'true'
Element minimum cardinalities differ: '0' vs '1'

end

ΣC

0..1

End time with inclusive boundary, if not ongoing

ΣC

0..1

End time with inclusive boundary, if not ongoing

created

SΣ

1..1

Response creation date

SΣ

1..1

Response creation date

enterer

0..1

Reference(Practitioner | PractitionerRole)

Author of the claim

0..1

Reference(Practitioner | PractitionerRole)

Author of the claim

insurer

SΣ

1..1

Party responsible for reimbursement

SΣ

1..1

Party responsible for reimbursement

provider

SΣ

1..1

Party responsible for the claim

SΣ

1..1

Party responsible for the claim

priority

0..1

Desired processing urgency
Binding: ProcessPriorityCodes (required)

0..1

Desired processing urgency
Binding: ProcessPriorityCodes (required)

fundsReserveRequested

0..1

For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

0..1

For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

fundsReserve

0..1

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

0..1

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

0..*

Prior or corollary claims

0..*

Prior or corollary claims

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

claim

0..1

Reference to the related claim

0..1

Reference to the related claim

relationship

1..1

How the reference claim is related
Binding: C4BBRelatedClaimRelationshipCodes (required)

1..1

How the reference claim is related
Binding: C4BB Related Claim Relationship Codes Value Set (required)

reference

1..1

File or case reference

1..1

Reference(MedicationRequest)

File or case reference

prescription

0..1

Reference(MedicationRequest | VisionPrescription)

Prescription authorizing services or products

0..1

Reference(MedicationRequest | VisionPrescription)

Prescription authorizing services or products

originalPrescription

0..1

Original prescription if superceded by fulfiller

0..1

Reference(MedicationRequest)

Original prescription if superceded by fulfiller

payee

0..1

Recipient of benefits payable

0..1

Recipient of benefits payable

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

type

1..1

Category of recipient
Binding: C4BBPayeeType (required)

1..1

Reference(ServiceRequest)

Category of recipient
Binding: C4BB Payee Type Value Set (required)

party

0..1

Reference(C4BB Organization | C4BB Patient | C4BB Practitioner)

Recipient reference

0..1

Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)

Recipient reference

referral

0..1

Treatment Referral

0..1

Reference(ServiceRequest)

Treatment Referral

facility

0..1

Reference(Location)

Servicing Facility

0..1

Reference(Location)

Servicing Facility

claim

0..1

Claim reference

0..1

Claim reference

claimResponse

0..1

Reference(ClaimResponse)

Claim response reference

0..1

Reference(ClaimResponse)

Claim response reference

outcome

SΣ

1..1

queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

SΣ

1..1

queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

disposition

0..1

Disposition Message

0..1

Disposition Message

preAuthRef

0..*

Preauthorization reference

0..*

Preauthorization reference

preAuthRefPeriod

0..*

Preauthorization in-effect period

0..*

Preauthorization in-effect period

careTeam

0..*

Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
EOB-careteam-qualification: Care Team Performing physician's qualifications are from Healthcare Provider Taxonomy Value Set

0..*

Care Team members
EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner
EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization
EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Order of care team

1..1

Order of care team

provider

1..1

Reference(C4BB Organization | C4BB Practitioner)

Practitioner or organization

1..1

Reference(C4BB Organization | C4BB Practitioner)

Practitioner or organization

responsible

0..1

Indicator of the lead practitioner

0..1

Indicator of the lead practitioner

role

1..1

Function within the team
Binding: C4BBClaimInstitutionalCareTeamRole (required)

1..1

Function within the team
Binding: C4BB Claim Institutional Care Team Role Value Set (required)

qualification

0..1

Practitioner credential or specialization
Binding: HealthcareProviderTaxonomy (required)

0..1

Practitioner credential or specialization
Binding: Healthcare Provider Taxonomy (required)

Slices for supportingInfo

1..*

Supporting information
Slice: Unordered, Open by pattern:category

0..*

Supporting information
Slice: Unordered, Open by pattern:category

Element minimum cardinalities differ: '1' vs '0'

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Information instance identifier

1..1

Information instance identifier

category

1..1

Classification of the supplied information
Binding: C4BBSupportingInfoType (extensible)

1..1

Classification of the supplied information
Binding: C4BB SupportingInfo Type Value Set (extensible)

code

0..1

Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

0..1

Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

timing[x]

0..1

When it occurred

0..1

When it occurred

value[x]

0..1

boolean, string, Quantity, Attachment, Reference(Resource)

Data to be provided

0..1

boolean, string, Quantity, Attachment, Reference(Resource)

Data to be provided

reason

0..1

Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

0..1

Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

diagnosis

1..*

Pertinent diagnosis information

1..*

Pertinent diagnosis information

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Diagnosis instance identifier

1..1

Diagnosis instance identifier

diagnosis[x]

1..1

Nature of illness or problem
Binding: CDCICD910CMDiagnosisCodes (required)

1..1

Nature of illness or problem
Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required)

type

1..1

Timing or nature of the diagnosis
Binding: C4BBClaimOutpatientInstitutionalDiagnosisType (required)

1..1

Timing or nature of the diagnosis
Binding: C4BB Claim Outpatient Institutional Diagnosis Type Value Set (required)

onAdmission

0..1

Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

0..1

Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

packageCode

0..1

Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

0..1

Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

procedure

0..*

Clinical procedures performed

0..*

Clinical procedures performed

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Procedure instance identifier

1..1

Procedure instance identifier

type

0..*

Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.

0..*

Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.

date

0..1

When the procedure was performed

0..1

When the procedure was performed

procedure[x]

1..1

CodeableConcept, Reference(Procedure)

Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

1..1

CodeableConcept, Reference(Procedure)

Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

udi

0..*

Unique device identifier

0..*

Unique device identifier

precedence

0..1

Precedence (primary, secondary, etc.)

0..1

Precedence (primary, secondary, etc.)

insurance

SΣC

1..*

Patient insurance information

SΣC

1..*

Patient insurance information

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

focal

SΣ

1..1

Coverage to be used for adjudication

SΣ

1..1

Coverage to be used for adjudication

coverage

SΣ

1..1

Reference(C4BB Coverage)

Insurance information

SΣ

1..1

Reference(C4BB Coverage)

Insurance information

preAuthRef

0..*

Prior authorization reference number

0..*

Prior authorization reference number

accident

0..1

Details of the event

0..1

Details of the event

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

date

0..1

When the incident occurred

0..1

When the incident occurred

type

0..1

The nature of the accident
Binding: V3 Value SetActIncidentCode (extensible): Type of accident: work place, auto, etc.

0..1

The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

location[x]

0..1

Address, Reference(Location)

Where the event occurred

0..1

Address, Reference(Location)

Where the event occurred

item

1..*

Product or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice

1..*

Product or service provided
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Item instance identifier

1..1

Item instance identifier

careTeamSequence

0..*

Applicable care team members

0..*

Applicable care team members

diagnosisSequence

0..*

Applicable diagnoses

0..*

Applicable diagnoses

procedureSequence

0..*

Applicable procedures

0..*

Applicable procedures

informationSequence

0..*

Applicable exception and supporting information

0..*

Applicable exception and supporting information

revenue

0..1

Revenue or cost center code
Binding: AHANUBCRevenueCodes (required)

0..1

Revenue or cost center code
Binding: NUBC Revenue Codes Value Set (required)

category

0..1

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

0..1

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

productOrService

1..1

Billing, service, product, or drug code
Binding: C4BBEOBInstitutionalProcedureCodes (required)

1..1

Billing, service, product, or drug code
Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required)

modifier

0..*

Product or service billing modifiers
Binding: AMACPTCMSHCPCSModifiers (required)

0..*

Product or service billing modifiers
Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required)

programCode

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

Slices for serviced[x]

1..1

Date or dates of service or product delivery
Slice: Unordered, Closed by type:$this

1..1

Date or dates of service or product delivery
Slice: Unordered, Closed by type:$this

location[x]

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

udi

0..*

Unique device identifier

0..*

Unique device identifier

bodySite

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

subSite

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

encounter

0..*

Reference(Encounter)

Encounters related to this billed item

0..*

Reference(Encounter)

Encounters related to this billed item

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

Slices for adjudication

0..*

Adjudication details
Slice: Unordered, Open by pattern:category

0..*

Adjudication details
Slice: Unordered, Open by pattern:category

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

category

1..1

Type of adjudication information
Binding: C4BBAdjudicationCategoryDiscriminator (required)

1..1

Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)

reason

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

amount

0..1

Monetary amount

0..1

Monetary amount

value

0..1

Non-monitary value

0..1

Non-monitary value

detail

0..*

Additional items

0..*

Additional items

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Product or service provided

1..1

Product or service provided

revenue

0..1

Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

0..1

Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

category

0..1

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

0..1

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

productOrService

1..1

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

1..1

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

modifier

0..*

Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

0..*

programCode

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

udi

0..*

Unique device identifier

0..*

Unique device identifier

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

adjudication

0..*

Detail level adjudication details

0..*

Detail level adjudication details

subDetail

0..*

Additional items

0..*

Additional items

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Product or service provided

1..1

Product or service provided

revenue

0..1

Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

0..1

Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

category

0..1

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

0..1

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

productOrService

1..1

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

1..1

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

modifier

0..*

0..*

programCode

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

udi

0..*

Unique device identifier

0..*

Unique device identifier

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

adjudication

0..*

Subdetail level adjudication details

0..*

Subdetail level adjudication details

addItem

0..*

Insurer added line items

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

itemSequence

0..*

Item sequence number

0..*

Item sequence number

detailSequence

0..*

Detail sequence number

0..*

Detail sequence number

subDetailSequence

0..*

Subdetail sequence number

0..*

Subdetail sequence number

provider

0..*

Reference(Practitioner | PractitionerRole | Organization)

Authorized providers

0..*

Reference(Practitioner | PractitionerRole | Organization)

Authorized providers

productOrService

1..1

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

1..1

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

modifier

0..*

0..*

programCode

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

0..*

Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.

serviced[x]

0..1

Date or dates of service or product delivery

0..1

Date or dates of service or product delivery

location[x]

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

bodySite

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

subSite

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

adjudication

0..*

Added items adjudication

0..*

Added items adjudication

detail

0..*

Insurer added line items

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

productOrService

1..1

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

1..1

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

modifier

0..*

0..*

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

adjudication

0..*

Added items adjudication

0..*

Added items adjudication

subDetail

0..*

Insurer added line items

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

productOrService

1..1

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

1..1

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

modifier

0..*

0..*

quantity

0..1

Count of products or services

0..1

Count of products or services

unitPrice

0..1

Fee, charge or cost per item

0..1

Fee, charge or cost per item

factor

0..1

Price scaling factor

0..1

Price scaling factor

net

0..1

Total item cost

0..1

Total item cost

noteNumber

0..*

Applicable note numbers

0..*

Applicable note numbers

adjudication

0..*

Added items adjudication

0..*

Added items adjudication

Slices for adjudication

0..*

Header-level adjudication
Slice: Unordered, Open by pattern:category

1..*

Header-level adjudication
Slice: Unordered, Open by pattern:category

Element minimum cardinalities differ: '0' vs '1'

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

category

1..1

Type of adjudication information
Binding: C4BBAdjudicationCategoryDiscriminator (required)

1..1

Type of adjudication information
Binding: C4BB Adjudication Category Discriminator Value Set (extensible)

reason

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

amount

0..1

Monetary amount

0..1

Monetary amount

value

0..1

Non-monitary value

0..1

Non-monitary value

Slices for total

SΣ

1..*

Adjudication totals
Slice: Unordered, Open by pattern:category

SΣ

1..*

Adjudication totals
Slice: Unordered, Open by pattern:category

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

category

SΣ

1..1

Type of adjudication information
Binding: C4BBTotalCategoryDiscriminator (extensible)

SΣ

1..1

Type of adjudication information
Binding: C4BB Total Category Discriminator Value Set (extensible)

amount

1..1

Financial total for the category

1..1

Financial total for the category

payment

0..1

Payment Details

0..1

Payment Details

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

type

0..1

Partial or complete payment
Binding: C4BBPayerClaimPaymentStatusCode (required)

0..1

Partial or complete payment
Binding: C4BB Payer Claim Payment Status Code Value Set (required)

adjustment

0..1

Payment adjustment for non-claim issues

0..1

Payment adjustment for non-claim issues

adjustmentReason

0..1

Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

0..1

Explanation for the variance
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

date

0..1

Expected date of payment

0..1

Expected date of payment

amount

0..1

Payable amount after adjustment

0..1

Payable amount after adjustment

identifier

0..1

Business identifier for the payment

0..1

Business identifier for the payment

formCode

0..1

Printed form identifier
Binding: Form Codes (example): The forms codes.

0..1

Printed form identifier
Binding: Form Codes (example): The forms codes.

form

0..1

Attachment

Printed reference or actual form

0..1

Attachment

Printed reference or actual form

processNote

0..*

Note concerning adjudication

0..*

Note concerning adjudication

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

number

0..1

Note instance identifier

0..1

Note instance identifier

type

0..1

display | print | printoper
Binding: NoteType (required): The presentation types of notes.

0..1

display | print | printoper
Binding: NoteType (required): The presentation types of notes.

text

0..1

Note explanatory text

0..1

Note explanatory text

language

0..1

Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

0..1

Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

benefitPeriod

0..1

When the benefits are applicable

0..1

When the benefits are applicable

benefitBalance

0..*

Balance by Benefit Category

0..*

Balance by Benefit Category

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

category

1..1

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

1..1

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

excluded

0..1

Excluded from the plan

0..1

Excluded from the plan

name

0..1

Short name for the benefit

0..1

Short name for the benefit

description

0..1

Description of the benefit or services covered

0..1

Description of the benefit or services covered

network

0..1

In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

0..1

In or out of network
Binding: NetworkTypeCodes (example): Code to classify in or out of network services.

unit

0..1

Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

0..1

Individual or family
Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.

term

0..1

Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

0..1

Annual or lifetime
Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.

financial

0..*

Benefit Summary

0..*

Benefit Summary

0..1

Unique id for inter-element referencing

0..1

Unique id for inter-element referencing

extension

0..*

Additional content defined by implementations

0..*

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

type

1..1

Benefit classification
Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.

1..1