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 and amount types of the claim are to be provided in EOB.total.  The in network or out of network payment status of the claim are to be provided in EOB.supportingInfo.
• ExplanationOfBenefit.item.productOrService:  values are NDC Codes when Compound Code (MapID 78) = 0 or 1.  When the Compound Code = 2, productOrService = "compound" and map the ingredient to ExplanationOfBenefit.item.detail.productOrService
• ExplanationOfBenefit.item.productOrService and item.detail.productOrService: Payers shall provide an 11-digit NDC. For additional information, reference the Other useful Information in the HL7 Terminology Authority - External Terminologies - NDC Confluence site, https://confluence.hl7.org/pages/viewpage.action?pageId=97453858
• ExplanationOfBenefit.item.quantity:  populate for all Compound Code values.  When the Compound Code = 2, if available, map the ingredient to ExplanationOfBenefit.item.detail.quantity
• ExplanationOfBenefit.item.adjudication.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  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). 
• ExplanationOfBenefit.total.amount:  Eligible amount = ingredient cost + dispensing fee + sales tax + vaccine administration fee.  Excludes manufacturer discounts.  If benefit payment status code = 'Y', discount = submitted – noncovered – eligible; otherwise discount = 0.  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). 
• ExplanationOfBenefit.adjudication[benefitpaymentstatus]:  in network or out of network payment status for the claim
• The CPCDS data elements are defined in the data element comments.  The numbers, e.g. (1), following the data element descriptions in the comments correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
• meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from C4BBExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
identifier	S	1..*	Identifier	Business Identifier for the resource
type		1..1	CodeableConcept	Category or discipline Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
created	S	1..1	dateTime	Response creation date
careTeam	C	0..*	BackboneElement	Care Team members EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
role		1..1	CodeableConcept	Function within the team Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
Slices for supportingInfo		4..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:dayssupply	S	1..1	BackboneElement	Days supply
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dayssupply
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:dawcode	S	1..1	BackboneElement	Dispense and written product selection code
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dawcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
supportingInfo:refillNum	S	1..1	BackboneElement	The number fill of the claim dispensed supply
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillnum
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:refillsAuthorized		1..1	BackboneElement	Number or refills authorized by prescriber
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillsauthorized
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:brandgenericindicator	S	0..1	BackboneElement	Plan reported brand or generic drug indicator
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: brandgenericindicator
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Brand Generic Indicator Value Set (required)
supportingInfo:rxoriginCode	S	0..1	BackboneElement	Prescription origin code
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rxorigincode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Prescription Origin Code Value Set (required)
supportingInfo:clmrecvddate	S	0..1	BackboneElement	Claim received date
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: clmrecvddate
timing[x]	S	1..1	date	When it occurred
supportingInfo:compoundcode	S	0..1	BackboneElement	Code indicating whether or not the prescription is a compound
category	S	1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: compoundcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Compound Code Value Set (required)
item
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: NDC or Compound Value Set (required)
serviced[x]		1..1	date	Date or dates of service or product delivery Slice: Unordered, Open by type:$this
servicedDate	S	1..1	date	Date or dates of service or product delivery
quantity	S	0..1	SimpleQuantity	Count of products or services
Slices for adjudication	S	1..*	BackboneElement	Adjudication details Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
adjudication:adjudicationamounttype	S	1..*	BackboneElement	Line level adjudication type and amount
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
amount	S	1..1	Money	Monetary amount
adjudication:rejectreason	S	0..1	BackboneElement	Reason codes used to interpret the Non-Covered Amount (92)
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rejectreason
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: NCPDP Reject Code Value Set (required)
detail	S	0..*	BackboneElement	Additional items
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: National Drug Code (NDC) Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Slices for adjudication	S	1..*	BackboneElement	Header-level adjudication Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
adjudication:billingnetworkstatus	S	0..1	BackboneElement	Billing provider networking status
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required)
adjudication:benefitpaymentstatus	S	1..1	BackboneElement	Indicates the in network or out of network payment status of the claim. (142)
category		1..1	CodeableConcept	Type of adjudication information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required)
Slices for total		1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by pattern:category
total:All Slices				Content/Rules for all slices
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Total Category Discriminator Value Set (extensible)
amount	S	1..1	Money	Financial total for the category
total:adjudicationamounttype	S	1..*	BackboneElement	Total adjudication type and amount
category		1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
amount	S	1..1	Money	Financial total for the category
payment
date	S	0..1	date	Expected date of payment
processNote
text	S	0..1	string	Note explanatory text
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
ExplanationOfBenefit.careTeam.role	required	C4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo:dawcode.code	required	NCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:brandgenericindicator.code	required	NCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.code	required	NCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:compoundcode.code	required	NCPDPCompoundCode
ExplanationOfBenefit.item.productOrService	required	FDANDCOrCompound
ExplanationOfBenefit.item.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	C4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.reason	required	NCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrService	required	FDANationalDrugCode
ExplanationOfBenefit.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason	required	C4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason	required	C4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.category	extensible	C4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.category	required	C4BBAdjudication

Constraints

Id	Grade	Path(s)	Details	Requirements
EOB-pharm-careTeam-organization	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to an organization : ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitioner	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-version	error	ExplanationOfBenefit	Pharmacy 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-Pharmacy|2.0.'))

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
meta	SΣ	1..1	Meta	Metadata about the resource
lastUpdated	SΣ	1..1	instant	When the resource version last changed
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	S	1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by pattern:type
identifier:uniqueclaimid	S	1..1	Identifier	Unique Claim Identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	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. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: uc
value	SΣ	1..1	string	Unique Claim Identifier Example General: 123456
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
use	SΣ	1..1	code	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
billablePeriod	SΣ	1..1	Period	Relevant time frame for the claim
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(C4BB Organization)	Party responsible for reimbursement
provider	SΣ	1..1	Reference(C4BB Organization | C4BB Practitioner)	Party responsible for the claim
related	S	0..*	BackboneElement	Prior or corollary claims
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required)
reference	S	1..1	Identifier	File or case reference
payee	SC	0..1	BackboneElement	Recipient of benefits payable
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Category of recipient Binding: C4BB Payee Type Value Set (required)
party	S	0..1	Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)	Recipient reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
careTeam	SC	0..*	BackboneElement	Care Team members EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(C4BB Organization | C4BB Practitioner)	Practitioner or organization
role	S	1..1	CodeableConcept	Function within the team Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
Slices for supportingInfo	S	4..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible)
supportingInfo:dayssupply	S	1..1	BackboneElement	Days supply
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dayssupply
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:dawcode	S	1..1	BackboneElement	Dispense and written product selection code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dawcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
supportingInfo:refillNum	S	1..1	BackboneElement	The number fill of the claim dispensed supply
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillnum
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:refillsAuthorized	S	1..1	BackboneElement	Number or refills authorized by prescriber
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillsauthorized
value[x]	S	1..1	Quantity	Data to be provided
supportingInfo:brandgenericindicator	S	0..1	BackboneElement	Plan reported brand or generic drug indicator
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: brandgenericindicator
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Brand Generic Indicator Value Set (required)
supportingInfo:rxoriginCode	S	0..1	BackboneElement	Prescription origin code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rxorigincode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Prescription Origin Code Value Set (required)
supportingInfo:clmrecvddate	S	0..1	BackboneElement	Claim received date
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: clmrecvddate
timing[x]	S	1..1	date	When it occurred
supportingInfo:compoundcode	S	0..1	BackboneElement	Code indicating whether or not the prescription is a compound
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
code		1..1	code	Symbol in syntax defined by the system Fixed Value: compoundcode
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Compound Code Value Set (required)
insurance	SΣC	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication
coverage	SΣ	1..1	Reference(C4BB Coverage)	Insurance information
item	S	1..*	BackboneElement	Product or service provided
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: NDC or Compound Value Set (required)
Slices for serviced[x]		1..1	date	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedDate	S	1..1	date	Date or dates of service or product delivery
quantity	S	0..1	SimpleQuantity	Count of products or services
noteNumber	S	0..*	positiveInt	Applicable note numbers
Slices for adjudication	S	1..*	BackboneElement	Adjudication details Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
adjudication:adjudicationamounttype	S	1..*	BackboneElement	Line level adjudication type and amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
amount	S	1..1	Money	Monetary amount
adjudication:rejectreason	S	0..1	BackboneElement	Reason codes used to interpret the Non-Covered Amount (92)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rejectreason
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: NCPDP Reject Code Value Set (required)
detail	S	0..*	BackboneElement	Additional items
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: National Drug Code (NDC) Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Slices for adjudication	S	1..*	BackboneElement	Header-level adjudication Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
adjudication:billingnetworkstatus	S	0..1	BackboneElement	Billing provider networking status
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required)
adjudication:benefitpaymentstatus	S	1..1	BackboneElement	Indicates the in network or out of network payment status of the claim. (142)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required)
Slices for total	SΣ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by pattern:category
total:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Total Category Discriminator Value Set (extensible)
amount	SΣ	1..1	Money	Financial total for the category
total:adjudicationamounttype	SΣ	1..*	BackboneElement	Total adjudication type and amount
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
amount	SΣ	1..1	Money	Financial total for the category
payment	S	0..1	BackboneElement	Payment Details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	0..1	CodeableConcept	Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required)
date	S	0..1	date	Expected date of payment
processNote	S	0..*	BackboneElement	Note concerning adjudication
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
text	S	0..1	string	Note explanatory text
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ExplanationOfBenefit.identifier:uniqueclaimid.use	required	IdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.type	extensible	Pattern: uc
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus
ExplanationOfBenefit.type	required	Pattern: pharmacy
ExplanationOfBenefit.use	required	Pattern: claim
ExplanationOfBenefit.related.relationship	required	C4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.type	required	C4BBPayeeType
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes
ExplanationOfBenefit.careTeam.role	required	C4BBClaimPharmacyTeamRole
ExplanationOfBenefit.supportingInfo.category	extensible	C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo:dayssupply.category	extensible	Pattern: dayssupply
ExplanationOfBenefit.supportingInfo:dawcode.category	extensible	Pattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.code	required	NCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:refillNum.category	extensible	Pattern: refillnum
ExplanationOfBenefit.supportingInfo:refillsAuthorized.category	extensible	Pattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:brandgenericindicator.category	extensible	Pattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.code	required	NCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:rxoriginCode.category	extensible	Pattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.code	required	NCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:clmrecvddate.category	extensible	Pattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:compoundcode.category	extensible	Pattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.code	required	NCPDPCompoundCode
ExplanationOfBenefit.item.productOrService	required	FDANDCOrCompound
ExplanationOfBenefit.item.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	C4BBAdjudication
ExplanationOfBenefit.item.adjudication:rejectreason.category	example	Pattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reason	required	NCPDPRejectCode
ExplanationOfBenefit.item.detail.productOrService	required	FDANationalDrugCode
ExplanationOfBenefit.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication:billingnetworkstatus.category	example	Pattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason	required	C4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category	example	Pattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason	required	C4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.category	extensible	C4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.category	required	C4BBAdjudication
ExplanationOfBenefit.payment.type	required	C4BBPayerClaimPaymentStatusCode

Constraints

Id	Grade	Path(s)	Details	Requirements
EOB-pharm-careTeam-organization	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to an organization : ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitioner	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharmacy-meta-profile-version	error	ExplanationOfBenefit	Pharmacy 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-Pharmacy|2.0.'))

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	C4BBExplanationOfBenefit	Explanation of Benefit resource EOB-pharmacy-meta-profile-version: Pharmacy EOB: meta.profile with canonical and major.minor. version required.
id	Σ	0..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	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	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	S	1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by pattern:type
identifier:uniqueclaimid	S	1..1	Identifier	Unique Claim Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	1..1	CodeableConcept	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. Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: uc
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	Unique Claim Identifier Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	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
billablePeriod	SΣ	1..1	Period	Relevant time frame for the claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
created	SΣ	1..1	dateTime	Response creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(C4BB Organization)	Party responsible for reimbursement
provider	SΣ	1..1	Reference(C4BB Organization | C4BB Practitioner)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related	S	0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: C4BB Related Claim Relationship Codes Value Set (required)
reference	S	1..1	Identifier	File or case reference
prescription		0..1	Reference(MedicationRequest | VisionPrescription)	Prescription authorizing services or products
originalPrescription		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller
payee	SC	0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Category of recipient Binding: C4BB Payee Type Value Set (required)
party	S	0..1	Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment Referral
facility		0..1	Reference(Location)	Servicing Facility
claim		0..1	Reference(Claim)	Claim reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference
preAuthRefPeriod		0..*	Period	Preauthorization in-effect period
careTeam	SC	0..*	BackboneElement	Care Team members EOB-pharm-careTeam-practitioner: Pharmacy EOB: Careteam roles refer to a practitioner EOB-pharm-careTeam-organization: Pharmacy EOB: Careteam roles refer to an organization
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(C4BB Organization | C4BB Practitioner)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	1..1	CodeableConcept	Function within the team Binding: C4BB Claim Pharmacy CareTeam Role Value Set (required)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
Slices for supportingInfo	S	4..*	BackboneElement	Supporting information Slice: Unordered, Open by pattern:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:dayssupply	S	1..1	BackboneElement	Days supply
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dayssupply
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:dawcode	S	1..1	BackboneElement	Dispense and written product selection code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dawcode
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Dispense As Written (DAW)/Product Selection Code Value Set (required)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:refillNum	S	1..1	BackboneElement	The number fill of the claim dispensed supply
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillnum
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:refillsAuthorized	S	1..1	BackboneElement	Number or refills authorized by prescriber
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: refillsauthorized
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]	S	1..1	Quantity	Data to be provided
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:brandgenericindicator	S	0..1	BackboneElement	Plan reported brand or generic drug indicator
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: brandgenericindicator
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Brand Generic Indicator Value Set (required)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:rxoriginCode	S	0..1	BackboneElement	Prescription origin code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rxorigincode
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Prescription Origin Code Value Set (required)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:clmrecvddate	S	0..1	BackboneElement	Claim received date
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: clmrecvddate
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]	S	1..1	date	When it occurred
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:compoundcode	S	0..1	BackboneElement	Code indicating whether or not the prescription is a compound
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible) Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: compoundcode
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	S	1..1	CodeableConcept	Type of information Binding: NCPDP Compound Code Value Set (required)
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	SΣC	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	SΣ	1..1	boolean	Coverage to be used for adjudication
coverage	SΣ	1..1	Reference(C4BB Coverage)	Insurance information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence		0..*	positiveInt	Applicable care team members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: NDC or Compound Value Set (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x]		1..1	date	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedDate	S	1..1	date	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.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	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
noteNumber	S	0..*	positiveInt	Applicable note numbers
Slices for adjudication	S	1..*	BackboneElement	Adjudication details Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:adjudicationamounttype	S	1..*	BackboneElement	Line level adjudication type and amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount	S	1..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:rejectreason	S	0..1	BackboneElement	Reason codes used to interpret the Non-Covered Amount (92)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: rejectreason
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: NCPDP Reject Code Value Set (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
detail	S	0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: National Drug Code (NDC) Value Set (required)
modifier		0..*	CodeableConcept	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.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details
subDetail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	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.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subDetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	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.
programCode		0..*	CodeableConcept	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
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	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.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	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.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
Slices for adjudication	S	1..*	BackboneElement	Header-level adjudication Slice: Unordered, Open by pattern:category
adjudication:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Category Discriminator Value Set (extensible)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:billingnetworkstatus	S	0..1	BackboneElement	Billing provider networking status
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: billingnetworkstatus
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Provider Network Status Value Set (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:benefitpaymentstatus	S	1..1	BackboneElement	Indicates the in network or out of network payment status of the claim. (142)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: C4BB Payer Benefit Payment Status Value Set (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
Slices for total	SΣ	1..*	BackboneElement	Adjudication totals Slice: Unordered, Open by pattern:category
total:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Total Category Discriminator Value Set (extensible)
amount	SΣ	1..1	Money	Financial total for the category
total:adjudicationamounttype	SΣ	1..*	BackboneElement	Total adjudication type and amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: C4BB Adjudication Value Set (required)
amount	SΣ	1..1	Money	Financial total for the category
payment	S	0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	0..1	CodeableConcept	Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date	S	0..1	date	Expected date of payment
amount		0..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote	S	0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text	S	0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
benefitPeriod		0..1	Period	When the benefits are applicable
benefitBalance		0..*	BackboneElement	Balance by Benefit Category
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedMoney			Money
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ExplanationOfBenefit.meta.security	extensible	All Security Labels
ExplanationOfBenefit.meta.tag	example	CommonTags
ExplanationOfBenefit.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.identifier:uniqueclaimid.use	required	IdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.type	extensible	Pattern: uc
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus
ExplanationOfBenefit.type	required	Pattern: pharmacy
ExplanationOfBenefit.subType	example	ExampleClaimSubTypeCodes
ExplanationOfBenefit.use	required	Pattern: claim
ExplanationOfBenefit.priority	required	ProcessPriorityCodes
ExplanationOfBenefit.fundsReserveRequested	example	Funds Reservation Codes
ExplanationOfBenefit.fundsReserve	example	Funds Reservation Codes
ExplanationOfBenefit.related.relationship	required	C4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.type	required	C4BBPayeeType
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes
ExplanationOfBenefit.careTeam.role	required	C4BBClaimPharmacyTeamRole
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes
ExplanationOfBenefit.supportingInfo.category	extensible	C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dayssupply.category	extensible	Pattern: dayssupply
ExplanationOfBenefit.supportingInfo:dayssupply.code	example	ExceptionCodes
ExplanationOfBenefit.supportingInfo:dayssupply.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:dawcode.category	extensible	Pattern: dawcode
ExplanationOfBenefit.supportingInfo:dawcode.code	required	NCPDPDispensedAsWrittenOrProductSelectionCode
ExplanationOfBenefit.supportingInfo:dawcode.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillNum.category	extensible	Pattern: refillnum
ExplanationOfBenefit.supportingInfo:refillNum.code	example	ExceptionCodes
ExplanationOfBenefit.supportingInfo:refillNum.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.category	extensible	Pattern: refillsauthorized
ExplanationOfBenefit.supportingInfo:refillsAuthorized.code	example	ExceptionCodes
ExplanationOfBenefit.supportingInfo:refillsAuthorized.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:brandgenericindicator.category	extensible	Pattern: brandgenericindicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.code	required	NCPDPBrandGenericIndicator
ExplanationOfBenefit.supportingInfo:brandgenericindicator.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:rxoriginCode.category	extensible	Pattern: rxorigincode
ExplanationOfBenefit.supportingInfo:rxoriginCode.code	required	NCPDPPrescriptionOriginCode
ExplanationOfBenefit.supportingInfo:rxoriginCode.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.category	extensible	Pattern: clmrecvddate
ExplanationOfBenefit.supportingInfo:clmrecvddate.code	example	ExceptionCodes
ExplanationOfBenefit.supportingInfo:clmrecvddate.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.supportingInfo:compoundcode.category	extensible	Pattern: compoundcode
ExplanationOfBenefit.supportingInfo:compoundcode.code	required	NCPDPCompoundCode
ExplanationOfBenefit.supportingInfo:compoundcode.reason	example	MissingToothReasonCodes
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes
ExplanationOfBenefit.item.category	example	BenefitCategoryCodes
ExplanationOfBenefit.item.productOrService	required	FDANDCOrCompound
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes
ExplanationOfBenefit.item.subSite	example	SurfaceCodes
ExplanationOfBenefit.item.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	C4BBAdjudication
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason	example	AdjudicationReasonCodes
ExplanationOfBenefit.item.adjudication:rejectreason.category	example	Pattern: rejectreason
ExplanationOfBenefit.item.adjudication:rejectreason.reason	required	NCPDPRejectCode
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrService	required	FDANationalDrugCode
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ExplanationOfBenefit.adjudication.category	extensible	C4BBAdjudicationCategoryDiscriminator
ExplanationOfBenefit.adjudication.reason	example	AdjudicationReasonCodes
ExplanationOfBenefit.adjudication:billingnetworkstatus.category	example	Pattern: billingnetworkstatus
ExplanationOfBenefit.adjudication:billingnetworkstatus.reason	required	C4BBPayerProviderNetworkStatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.category	example	Pattern: benefitpaymentstatus
ExplanationOfBenefit.adjudication:benefitpaymentstatus.reason	required	C4BBPayerBenefitPaymentStatus
ExplanationOfBenefit.total.category	extensible	C4BBTotalCategoryDiscriminator
ExplanationOfBenefit.total:adjudicationamounttype.category	required	C4BBAdjudication
ExplanationOfBenefit.payment.type	required	C4BBPayerClaimPaymentStatusCode
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ExplanationOfBenefit.formCode	example	Form Codes
ExplanationOfBenefit.processNote.type	required	NoteType
ExplanationOfBenefit.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ExplanationOfBenefit.benefitBalance.category	example	BenefitCategoryCodes
ExplanationOfBenefit.benefitBalance.network	example	NetworkTypeCodes
ExplanationOfBenefit.benefitBalance.unit	example	UnitTypeCodes
ExplanationOfBenefit.benefitBalance.term	example	BenefitTermCodes
ExplanationOfBenefit.benefitBalance.financial.type	example	BenefitTypeCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
EOB-pharm-careTeam-organization	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to an organization : ( role.where(coding.where(code in ('rendering' )).exists()).exists() implies role.where(coding.where(code in ('rendering' )).exists()).exists().provider.all(resolve() is Organization) )
EOB-pharm-careTeam-practitioner	error	ExplanationOfBenefit.careTeam	Pharmacy EOB: Careteam roles refer to a practitioner : ( role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists() implies role.where(coding.where(code in ('primary' | 'prescribing' )).exists()).exists().provider.all(resolve() is Organization) )