Synonyms:

• The Implementation Guide considers a health plan patient / beneficiary / member to be synonymous.  The subscriber is the member who carries the health coverage.  Subscriber synonyms include policy holder / insured.  The payer synonyms are insurer / health plan / payor
• The practitioner functional roles of rendering, rendering and servicing are synonymous.  CPCDS uses rendering
• The terms institutional and facility are synonymous.  CPCDS uses institutional
• The terms allowed and eligible are synonymous.  CPCDS uses eligible
• The terms disallowed and noncovered are synonymous.  CPCDS uses noncovered

Other Payer

CPCDS modified the concept of primary payer to other payer to accommodate situations when multiple prior payers are involved.  Each amount paid by the other payer should be listed separately.

Paths to the Patient Resource

There are two paths to get to the Patient Resource and the data elements represented inside the Patient Resource:  EOB.patient(Patient) and EOB.insurance.coverage(Coverage).beneficiary(Patient)

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
• .meta.lastUpdated: Payers SHALL provide the last time the data was updated or the date of creation in the payer’s system of record, whichever comes last.
• .status:  value =Expected values are active or cancelled. To comply with the CMS rule, draft EOBs are not required. 
• .type Defines the Claims profiles. Values from Claim Type Codes are required; data absent reason is not allowed
• .use: The CMS rule applies to adjudicated claims; it does not require preauthorizations or predeterminations.
• .patient  Additional required path:EOB.insurance.coverage(Coverage).beneficiary(Patient).identifier
• .insurer  Same as insurance.coverage.organization.  Party responsible for reimbursing the provider
• .outcome:  value = complete
• .related:  .related: Adjustment requests are used to change an original ExplanationOfBenefit information. The original payment can be increased or decreased, billed units can be changed, or other changes may occur. ExplanationOfBenefit.related captures the identifier of the prior / new ExplanationOfBenefit. If the current adjusts a prior ExplanationOfBenefit, .related.reference = the prior ExplanationOfBenefit identifier and related.relationship value = 'prior'. If the current ExplanationOfBenefit has been adjusted; related.reference = the ExplanationOfBenefit.identifier of the adjusting ExplanationOfBenefit and related.relationship value = 'replacedby'. The .related.reference contains the identifier of the immediately preceding or following ExplanationOfBenefit, not the first or last.
• .supportinginfo.sequence rule:  client app implementations should look-up supportingInfo elements based on category values instead of sequence values
• .careTeam.sequence rule:  careTeam.sequence values uniquely identify careTeam members.  They do not necessarily indicate any order in which the patient was seen by the careTeam or identify any level of significance of the careTeam to the patient, etc.  Client app implementations should not assign any significance to the sequence values.   
• .insurance:  Define an invariant:  Will have multiple occurrences on secondary / tertiary, etc. claims.  Up to one occurrence, that of the ExplanationOfBenefit.insurer, will have a boolean value = 'True'. 
• .insurance.focal:  If there is an occurrence, with focal = true, EOB.insurance.coverage.payor =  EOB.insurer is the same as EOB.insurance.coverage.payor.   (Coverage.payor is 1..1).  There can be  0 or * occurrences with focal = false
• .insurance.coverage:  When focal = true, Coverage.payer--> Organization.identifier.  When focal = false, EOB.insurance.coverage.display = [name of other carrier]  
• .insurance.coverage:  Same as insurance.coverage.organization.  Party responsible for reimbursing the provider.
• .item.noteNumber:  References number of the associated processNote entered
• 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 ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	This is an abstract profile. Child profiles: ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit Explanation of Benefit resource
meta	S	1..1	Meta	Metadata about the resource
lastUpdated	S	1..1	instant	When the resource version last changed
profile		1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
Slices for identifier		1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by pattern:type
identifier:All Slices				Content/Rules for all slices
type		0..1	CodeableConcept	Description of identifier
identifier:uniqueclaimid	S	1..1	Identifier	Unique Claim Identifier
type		1..1	CodeableConcept	Description of identifier 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	S	1..1	string	Unique Claim Identifier
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (required)
use	S	1..1	code	claim | preauthorization | predetermination Required Pattern: claim
patient	S	1..1	Reference(C4BB Patient)	The recipient of the products and services
billablePeriod	S	1..1	Period	Relevant time frame for the claim
start	S	1..1	dateTime	Starting time with inclusive boundary
end		0..1	dateTime	End time with inclusive boundary, if not ongoing
created		1..1	dateTime	Response creation date
insurer	S	1..1	Reference(C4BB Organization)	Party responsible for reimbursement
provider	S	1..1	Reference(C4BB Organization | C4BB Practitioner)	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
related	S	0..*	BackboneElement	Prior or corollary claims
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 EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
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	S	1..1	code	queued | complete | error | partial
careTeam	S	0..*	BackboneElement	Care Team members
sequence		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(C4BB Organization | C4BB Practitioner)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team
supportingInfo	S	0..*	BackboneElement	Supporting information
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: C4BB SupportingInfo Type Value Set (extensible)
insurance	SC	1..*	BackboneElement	Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true
focal	S	1..1	boolean	Coverage to be used for adjudication
coverage	S	1..1	Reference(C4BB Coverage)	Insurance information
item	S	1..*	BackboneElement	Product or service provided
sequence	S	1..1	positiveInt	Item instance identifier
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication
category	S	1..1	CodeableConcept	Type of adjudication information
total	S	1..*	BackboneElement	Adjudication totals
payment	S	0..1	BackboneElement	Payment Details
type	S	0..1	CodeableConcept	Partial or complete payment Binding: C4BB Payer Claim Payment Status Code Value Set (required)
date		0..1	date	Expected date of payment
processNote	S	0..*	BackboneElement	Note concerning adjudication
text		0..1	string	Note explanatory text
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
ExplanationOfBenefit.type	required	ClaimTypeCodes
ExplanationOfBenefit.priority	required	ProcessPriorityCodes
ExplanationOfBenefit.related.relationship	required	C4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.type	required	C4BBPayeeType
ExplanationOfBenefit.supportingInfo.category	extensible	C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.payment.type	required	C4BBPayerClaimPaymentStatusCode

Constraints

Id	Grade	Path(s)	Details	Requirements
EOB-insurance-focal	error	ExplanationOfBenefit.insurance	EOB.insurance: at most one with focal = true : insurance.select (focal = true).count() < 2
EOB-payee-other-type-requires-party	error	ExplanationOfBenefit.payee	Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	This is an abstract profile. Child profiles: ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit Explanation of Benefit resource
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		1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by pattern:type
identifier:All Slices				Content/Rules for all slices
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	0..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.
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)
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
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
created	Σ	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
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
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 EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
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	S	0..*	BackboneElement	Care Team members
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	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
supportingInfo	S	0..*	BackboneElement	Supporting information
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)
insurance	SΣC	1..*	BackboneElement	Patient insurance information EOB-insurance-focal: EOB.insurance: at most one with focal = true
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		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication		0..*	BackboneElement	Adjudication details
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.
total	SΣ	1..*	BackboneElement	Adjudication totals
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	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		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		0..1	string	Note explanatory text
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ExplanationOfBenefit.identifier.use	required	IdentifierUse
ExplanationOfBenefit.identifier.type	extensible	Identifier Type Codes
ExplanationOfBenefit.identifier:uniqueclaimid.use	required	IdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.type	extensible	Pattern: uc
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus
ExplanationOfBenefit.type	required	ClaimTypeCodes
ExplanationOfBenefit.use	required	Pattern: claim
ExplanationOfBenefit.priority	required	ProcessPriorityCodes
ExplanationOfBenefit.related.relationship	required	C4BBRelatedClaimRelationshipCodes
ExplanationOfBenefit.payee.type	required	C4BBPayeeType
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes
ExplanationOfBenefit.careTeam.role	example	ClaimCareTeamRoleCodes
ExplanationOfBenefit.supportingInfo.category	extensible	C4BBSupportingInfoType (a valid code from C4BB Supporting Info Type Code System)
ExplanationOfBenefit.item.productOrService	example	USCLSCodes
ExplanationOfBenefit.item.adjudication.category	example	AdjudicationValueCodes
ExplanationOfBenefit.total.category	example	AdjudicationValueCodes
ExplanationOfBenefit.payment.type	required	C4BBPayerClaimPaymentStatusCode

Constraints

Id	Grade	Path(s)	Details	Requirements
EOB-insurance-focal	error	ExplanationOfBenefit.insurance	EOB.insurance: at most one with focal = true : insurance.select (focal = true).count() < 2
EOB-payee-other-type-requires-party	error	ExplanationOfBenefit.payee	Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit		0..*	ExplanationOfBenefit	This is an abstract profile. Child profiles: ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit, ExplanationOfBenefit Explanation of Benefit resource
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		1..*	Identifier	Business Identifier for the resource Slice: Unordered, Open by pattern:type
identifier: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 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	0..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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique 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)
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)
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	Σ	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 EOB-payee-other-type-requires-party: Base EOB: if payee type is other, payee party is required
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	S	0..*	BackboneElement	Care Team members
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	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo	S	0..*	BackboneElement	Supporting 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	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.
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 EOB-insurance-focal: EOB.insurance: at most one with focal = true
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		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
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.
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
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
adjudication		0..*	BackboneElement	Adjudication 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
category	S	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
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
detail		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)	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
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Header-level adjudication
total	SΣ	1..*	BackboneElement	Adjudication totals
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: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	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		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		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.use	required	IdentifierUse
ExplanationOfBenefit.identifier.type	extensible	Identifier Type Codes
ExplanationOfBenefit.identifier:uniqueclaimid.use	required	IdentifierUse
ExplanationOfBenefit.identifier:uniqueclaimid.type	extensible	Pattern: uc
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus
ExplanationOfBenefit.type	required	ClaimTypeCodes
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	example	ClaimCareTeamRoleCodes
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.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	example	USCLSCodes
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	example	AdjudicationValueCodes
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes
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.total.category	example	AdjudicationValueCodes
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-insurance-focal	error	ExplanationOfBenefit.insurance	EOB.insurance: at most one with focal = true : insurance.select (focal = true).count() < 2
EOB-payee-other-type-requires-party	error	ExplanationOfBenefit.payee	Base EOB: if payee type is other, payee party is required : type.coding.where(code = 'other' and system = 'http://terminology.hl7.org/CodeSystem/payeetype').exists() implies party.exists()