Left: | C4BB ExplanationOfBenefit Outpatient Institutional (http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional) |
Right: | C4BB ExplanationOfBenefit Outpatient Institutional (http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional) |
Error | StructureDefinition.version | Values for version differ: '1.2.0' vs '2.0.0' |
Information | StructureDefinition.date | Values for date differ: '2021-12-06T20:26:50+00:00' vs '2022-11-28T15:29:06+00:00' |
Warning | ExplanationOfBenefit.identifier.type | Elements differ in comments: 'Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber. (183)' vs 'This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.' |
Warning | ExplanationOfBenefit.identifier.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
Information | ExplanationOfBenefit.identifier.type | Element minimum cardinalities differ: '1' vs '0' |
Information | ExplanationOfBenefit.billablePeriod | Element minimum cardinalities differ: '0' vs '1' |
Warning | ExplanationOfBenefit.billablePeriod.start | Elements differ in definition for mustSupport: 'false' vs 'true' |
Information | ExplanationOfBenefit.billablePeriod.start | Element minimum cardinalities differ: '0' vs '1' |
Information | ExplanationOfBenefit.supportingInfo | Element minimum cardinalities differ: '1' vs '0' |
Information | ExplanationOfBenefit.adjudication | Element minimum cardinalities differ: '0' vs '1' |
Name | Value | Comments | |
---|---|---|---|
abstract | false | ||
baseDefinition | http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit | ||
copyright | |||
date | 2021-12-06T20:26:50+00:00 | 2022-11-28T15:29:06+00:00 |
|
description | This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at an institution that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services. | ||
experimental | |||
fhirVersion | 4.0.1 | ||
jurisdiction | |||
jurisdiction[0] | urn:iso:std:iso:3166#US | ||
kind | resource | ||
name | C4BBExplanationOfBenefitOutpatientInstitutional | ||
publisher | HL7 Financial Management Working Group | ||
purpose | |||
status | active | ||
title | C4BB ExplanationOfBenefit Outpatient Institutional | ||
type | ExplanationOfBenefit | ||
url | http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Outpatient-Institutional | ||
version | 1.2.0 | 2.0.0 |
|
Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication at the item or header level, but not both adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | C | 0..* | C4BBExplanationOfBenefit | Explanation of Benefit resource EOB-institutional-outpatient-meta-profile-version: Institutional Outpatient EOB: meta.profile with canonical and major.minor. version required. EOB-inst-pointoforigin: Where Admission Type and Point of Origin slices exist, if Type of Admission code is Newborn, Point of Origin must be from Point of Origin - Newborn CodeSystem or Type of Admission is not Newborn and Point of Origin must be from Point of Origin Nonnewborn CodeSystem. EOB-institutional-item-or-header-adjudication: Institutional EOB: Should have adjudication with adjudicationamounttype slice at the item or header level, but not both | |||||||||
id | Σ | 0..1 | string | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
meta | SΣ | 1..1 | Meta | Metadata about the resource | SΣ | 1..1 | Meta | Metadata about the resource | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||||
versionId | Σ | 0..1 | id | Version specific identifier | Σ | 0..1 | id | Version specific identifier | |||||||||
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed | SΣ | 1..1 | instant | When the resource version last changed | |||||||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | Σ | 0..1 | uri | Identifies where the resource comes from | |||||||||
Slices for profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this | 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. | 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". | 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 | ?!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.
| 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
identifier | S | 1..* | Identifier | Business Identifier for the resource | S | 1..* | Identifier | Business Identifier for the resource Slice: Unordered, Open by pattern:type | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 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 . | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||||||
type | SΣ | 1..1 | CodeableConcept | Description of identifier Binding: C4BBClaimIdentifierType (extensible) | 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 | 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 | 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 | 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) | 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. | ?!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: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"institutional"}]} | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (required) Required Pattern: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/claim-type","code":"institutional"}]} | |||||||||
subType | S | 1..1 | CodeableConcept | More granular claim type Binding: C4BBInstitutionalClaimSubType (required) Required Pattern: {"coding":[{"system":"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType","code":"outpatient"}]} | S | 1..1 | CodeableConcept | More granular claim type Binding: C4BB Institutional Claim SubType Value Set (required) Required Pattern: {"coding":[{"system":"http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBInstitutionalClaimSubType","code":"outpatient"}]} | |||||||||
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: claim | 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 | SΣ | 1..1 | Reference(C4BB Patient) | The recipient of the products and services | |||||||||
billablePeriod | SΣ | 0..1 | Period | Relevant time frame for the claim | SΣ | 1..1 | Period | Relevant time frame for the claim |
| ||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||||
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary | SΣC | 1..1 | dateTime | Starting time with inclusive boundary |
| ||||||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | |||||||||
created | SΣ | 1..1 | dateTime | Response creation date | SΣ | 1..1 | dateTime | Response creation date | |||||||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||||||||
insurer | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for reimbursement | |||||||||
provider | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for the claim | SΣ | 1..1 | Reference(C4BB Organization) | Party responsible for the claim | |||||||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | 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). | 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). | 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 | S | 0..* | BackboneElement | Prior or corollary claims | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
claim | 0..1 | Reference(Claim) | Reference to the related claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||||||||
relationship | S | 1..1 | CodeableConcept | How the reference claim is related Binding: C4BBRelatedClaimRelationshipCodes (required) | 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 | S | 1..1 | Identifier | File or case reference | |||||||||
prescription | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||||||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | |||||||||||
payee | SC | 0..1 | BackboneElement | Recipient of benefits payable | SC | 0..1 | BackboneElement | Recipient of benefits payable | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
type | S | 1..1 | CodeableConcept | Category of recipient Binding: C4BBPayeeType (required) | 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) | Recipient reference | S | 0..1 | Reference(C4BB Organization | C4BB Patient | C4BB Practitioner | C4BB RelatedPerson) | Recipient reference | |||||||||
referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | 0..1 | Reference(ServiceRequest) | Treatment Referral | |||||||||||
facility | 0..1 | Reference(Location) | Servicing Facility | 0..1 | Reference(Location) | Servicing Facility | |||||||||||
claim | 0..1 | Reference(Claim) | Claim reference | 0..1 | Reference(Claim) | Claim reference | |||||||||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | 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. | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | |||||||||
disposition | 0..1 | string | Disposition Message | 0..1 | string | Disposition Message | |||||||||||
preAuthRef | 0..* | string | Preauthorization reference | 0..* | string | Preauthorization reference | |||||||||||
preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | 0..* | Period | Preauthorization in-effect period | |||||||||||
careTeam | SC | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization EOB-careteam-qualification: Care Team Performing physician's qualifications are from Healthcare Provider Taxonomy Value Set | SC | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to an organization EOB-careteam-qualification: Care Team Rendering physician's qualifications are from Healthcare Provider Taxonomy Value Set | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Order of care team | 1..1 | positiveInt | Order of care team | |||||||||||
provider | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | S | 1..1 | Reference(C4BB Organization | C4BB Practitioner) | Practitioner or organization | |||||||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | 0..1 | boolean | Indicator of the lead practitioner | |||||||||||
role | S | 1..1 | CodeableConcept | Function within the team Binding: C4BBClaimInstitutionalCareTeamRole (required) | S | 1..1 | CodeableConcept | Function within the team Binding: C4BB Claim Institutional Care Team Role Value Set (required) | |||||||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: HealthcareProviderTaxonomy (required) | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: Healthcare Provider Taxonomy (required) | |||||||||||
Slices for supportingInfo | S | 1..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by pattern:category |
| ||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Information instance identifier | 1..1 | positiveInt | Information instance identifier | |||||||||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: C4BBSupportingInfoType (extensible) | 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. | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||||||||
timing[x] | 0..1 | date, Period | When it occurred | 0..1 | date, Period | When it occurred | |||||||||||
value[x] | 0..1 | boolean, string, Quantity, Attachment, Reference(Resource) | Data to be provided | 0..1 | boolean, string, Quantity, Attachment, Reference(Resource) | Data to be provided | |||||||||||
reason | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||||||||
diagnosis | 1..* | BackboneElement | Pertinent diagnosis information | 1..* | BackboneElement | Pertinent diagnosis information | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Diagnosis instance identifier | 1..1 | positiveInt | Diagnosis instance identifier | |||||||||||
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: CDCICD910CMDiagnosisCodes (required) | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: Diagnosis Codes - International Classification of Diseases, Clinical Modification (ICD-9-CM, ICD-10-CM) Value Set (required) | |||||||||
type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BBClaimOutpatientInstitutionalDiagnosisType (required) | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: C4BB Claim Outpatient Institutional Diagnosis Type Value Set (required) | |||||||||
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | 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. | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||||||||
procedure | 0..* | BackboneElement | Clinical procedures performed | 0..* | BackboneElement | Clinical procedures performed | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Procedure instance identifier | 1..1 | positiveInt | Procedure instance identifier | |||||||||||
type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||||||||
date | 0..1 | dateTime | When the procedure was performed | 0..1 | dateTime | When the procedure was performed | |||||||||||
procedure[x] | 1..1 | CodeableConcept, Reference(Procedure) | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | 1..1 | CodeableConcept, Reference(Procedure) | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes. | |||||||||||
udi | 0..* | Reference(Device) | Unique device identifier | 0..* | Reference(Device) | Unique device identifier | |||||||||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||||||||
insurance | SΣC | 1..* | BackboneElement | Patient insurance information | SΣC | 1..* | BackboneElement | Patient insurance information | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
focal | SΣ | 1..1 | boolean | Coverage to be used for adjudication | SΣ | 1..1 | boolean | Coverage to be used for adjudication | |||||||||
coverage | SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information | SΣ | 1..1 | Reference(C4BB Coverage) | Insurance information | |||||||||
preAuthRef | 0..* | string | Prior authorization reference number | 0..* | string | Prior authorization reference number | |||||||||||
accident | 0..1 | BackboneElement | Details of the event | 0..1 | BackboneElement | Details of the event | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
date | 0..1 | date | When the incident occurred | 0..1 | date | When the incident occurred | |||||||||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: V3 Value SetActIncidentCode (extensible): Type of accident: work place, auto, etc. | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||||||||
location[x] | 0..1 | Address, Reference(Location) | Where the event occurred | 0..1 | Address, Reference(Location) | Where the event occurred | |||||||||||
item | SC | 1..* | BackboneElement | Product or service provided adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | SC | 1..* | BackboneElement | Product or service provided adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | S | 1..1 | positiveInt | Item instance identifier | S | 1..1 | positiveInt | Item instance identifier | |||||||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | 0..* | positiveInt | Applicable care team members | |||||||||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | 0..* | positiveInt | Applicable diagnoses | |||||||||||
procedureSequence | 0..* | positiveInt | Applicable procedures | 0..* | positiveInt | Applicable procedures | |||||||||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | 0..* | positiveInt | Applicable exception and supporting information | |||||||||||
revenue | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: AHANUBCRevenueCodes (required) | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: NUBC Revenue Codes Value Set (required) | |||||||||
category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | 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: C4BBEOBInstitutionalProcedureCodes (required) | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS Value Set (required) | |||||||||
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: AMACPTCMSHCPCSModifiers (required) | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: Procedure Modifier Codes - AMA CPT - CMS HCPCS Value Set (required) | |||||||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | 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 | 1..1 | date | Date or dates of service or product delivery Slice: Unordered, Closed by type:$this | |||||||||||
location[x] | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | |||||||||||
quantity | S | 0..1 | SimpleQuantity | Count of products or services | S | 0..1 | SimpleQuantity | Count of products or services | |||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
udi | 0..* | Reference(Device) | Unique device identifier | 0..* | Reference(Device) | Unique device identifier | |||||||||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | 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. | 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 | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||||||||
noteNumber | S | 0..* | positiveInt | Applicable note numbers | S | 0..* | positiveInt | Applicable note numbers | |||||||||
Slices for adjudication | S | 0..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category | S | 0..* | BackboneElement | Adjudication details Slice: Unordered, Open by pattern:category | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BBAdjudicationCategoryDiscriminator (required) | 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. | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||||||||
amount | 0..1 | Money | Monetary amount | 0..1 | Money | Monetary amount | |||||||||||
value | 0..1 | decimal | Non-monitary value | 0..1 | decimal | Non-monitary value | |||||||||||
detail | 0..* | BackboneElement | Additional items | 0..* | BackboneElement | Additional items | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Product or service provided | 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. | 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. | 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. | 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. | 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. | 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 | 0..1 | SimpleQuantity | Count of products or services | |||||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
udi | 0..* | Reference(Device) | Unique device identifier | 0..* | Reference(Device) | Unique device identifier | |||||||||||
noteNumber | 0..* | positiveInt | Applicable note numbers | 0..* | positiveInt | Applicable note numbers | |||||||||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||||||||
subDetail | 0..* | BackboneElement | Additional items | 0..* | BackboneElement | Additional items | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
sequence | 1..1 | positiveInt | Product or service provided | 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. | 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. | 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. | 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. | 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. | 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 | 0..1 | SimpleQuantity | Count of products or services | |||||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
udi | 0..* | Reference(Device) | Unique device identifier | 0..* | Reference(Device) | Unique device identifier | |||||||||||
noteNumber | 0..* | positiveInt | Applicable note numbers | 0..* | positiveInt | Applicable note numbers | |||||||||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details | |||||||||||
addItem | 0..* | BackboneElement | Insurer added line items | 0..* | BackboneElement | Insurer added line items | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
itemSequence | 0..* | positiveInt | Item sequence number | 0..* | positiveInt | Item sequence number | |||||||||||
detailSequence | 0..* | positiveInt | Detail sequence number | 0..* | positiveInt | Detail sequence number | |||||||||||
subDetailSequence | 0..* | positiveInt | Subdetail sequence number | 0..* | positiveInt | Subdetail sequence number | |||||||||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | 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. | 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. | 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. | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||||||||
serviced[x] | 0..1 | date, Period | Date or dates of service or product delivery | 0..1 | date, Period | Date or dates of service or product delivery | |||||||||||
location[x] | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered. | |||||||||||
quantity | 0..1 | SimpleQuantity | Count of products or services | 0..1 | SimpleQuantity | Count of products or services | |||||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | 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. | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||||||||
noteNumber | 0..* | positiveInt | Applicable note numbers | 0..* | positiveInt | Applicable note numbers | |||||||||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||||||||
detail | 0..* | BackboneElement | Insurer added line items | 0..* | BackboneElement | Insurer added line items | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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. | 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 | 0..1 | SimpleQuantity | Count of products or services | |||||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
noteNumber | 0..* | positiveInt | Applicable note numbers | 0..* | positiveInt | Applicable note numbers | |||||||||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||||||||
subDetail | 0..* | BackboneElement | Insurer added line items | 0..* | BackboneElement | Insurer added line items | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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. | 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 | 0..1 | SimpleQuantity | Count of products or services | |||||||||||
unitPrice | 0..1 | Money | Fee, charge or cost per item | 0..1 | Money | Fee, charge or cost per item | |||||||||||
factor | 0..1 | decimal | Price scaling factor | 0..1 | decimal | Price scaling factor | |||||||||||
net | 0..1 | Money | Total item cost | 0..1 | Money | Total item cost | |||||||||||
noteNumber | 0..* | positiveInt | Applicable note numbers | 0..* | positiveInt | Applicable note numbers | |||||||||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||||||||
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category | S | 1..* | BackboneElement | Header-level adjudication Slice: Unordered, Open by pattern:category |
| ||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BBAdjudicationCategoryDiscriminator (required) | 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. | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||||||||
amount | 0..1 | Money | Monetary amount | 0..1 | Money | Monetary amount | |||||||||||
value | 0..1 | decimal | Non-monitary value | 0..1 | decimal | Non-monitary value | |||||||||||
Slices for total | SΣ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | SΣ | 1..* | BackboneElement | Adjudication totals Slice: Unordered, Open by pattern:category | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
category | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BBTotalCategoryDiscriminator (extensible) | SΣ | 1..1 | CodeableConcept | Type of adjudication information Binding: C4BB Total Category Discriminator Value Set (extensible) | |||||||||
amount | Σ | 1..1 | Money | Financial total for the category | Σ | 1..1 | Money | Financial total for the category | |||||||||
payment | S | 0..1 | BackboneElement | Payment Details | S | 0..1 | BackboneElement | Payment Details | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
type | S | 0..1 | CodeableConcept | Partial or complete payment Binding: C4BBPayerClaimPaymentStatusCode (required) | 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 | 0..1 | Money | Payment adjustment for non-claim issues | |||||||||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||||||||
date | S | 0..1 | date | Expected date of payment | S | 0..1 | date | Expected date of payment | |||||||||
amount | 0..1 | Money | Payable amount after adjustment | 0..1 | Money | Payable amount after adjustment | |||||||||||
identifier | 0..1 | Identifier | Business identifier for the payment | 0..1 | Identifier | Business identifier for the payment | |||||||||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||||||||
form | 0..1 | Attachment | Printed reference or actual form | 0..1 | Attachment | Printed reference or actual form | |||||||||||
processNote | S | 0..* | BackboneElement | Note concerning adjudication | S | 0..* | BackboneElement | Note concerning adjudication | |||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
number | 0..1 | positiveInt | Note instance identifier | 0..1 | positiveInt | Note instance identifier | |||||||||||
type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||||||||
text | S | 0..1 | string | Note explanatory text | S | 0..1 | string | Note explanatory text | |||||||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||||||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | 0..1 | Period | When the benefits are applicable | |||||||||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | 0..* | BackboneElement | Balance by Benefit Category | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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 | 0..1 | boolean | Excluded from the plan | |||||||||||
name | 0..1 | string | Short name for the benefit | 0..1 | string | Short name for the benefit | |||||||||||
description | 0..1 | string | Description of the benefit or services covered | 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. | 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. | 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. | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||||||||
financial | 0..* | BackboneElement | Benefit Summary | 0..* | BackboneElement | Benefit Summary | |||||||||||
id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||||||||
allowed[x] | 0..1 | unsignedInt, string, Money | Benefits allowed | 0..1 | unsignedInt, string, Money | Benefits allowed | |||||||||||
used[x] | 0..1 | unsignedInt, Money | Benefits used | 0..1 | unsignedInt, Money | Benefits used | |||||||||||
Documentation for this format |