Generated Narrative: StructureDefinition davinci-pct-aeob Name Flags Card. Type Description & Constraints ExplanationOfBenefit <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( pct-aeob-1, pct-aeob-2, pct-aeob-3 )">C 0..* ExplanationOfBenefit Explanation of Benefit resource Constraints: pct-aeob-1, pct-aeob-2, pct-aeob-3 #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:gfeReference 1..* Reference(PCT GFE Bundle) The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB. URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeReference #xD; extension:serviceDescription SC 0..1 string Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription #xD; extension:outOfNetworkProviderInfo S 0..1 url In Network Provider Options Link URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/inNetworkProviderOptionsLink #xD; Slices for identifier 1..* Identifier Business Identifier for the resource Slice: Unordered, Open by value:type #xD; identifier:uniqueclaimid 1..1 Identifier Unique Claim ID #xD; type 1..1 CodeableConcept Description of identifier Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: UCID #xD; type 1..1 CodeableConcept Category or discipline Binding: ClaimTypeCodes (required) #xD; use 1..1 code claim | preauthorization | predetermination Required Pattern: predetermination #xD; patient 1..1 Reference(US Core Patient Profile(7.0.0)) The recipient of the products and services #xD; created 1..1 dateTime The date and time this estimate was calculated. #xD; insurer 1..1 Reference(PCT Organization) Party responsible for reimbursement #xD; provider 1..1 Reference(PCT Practitioner | PCT Organization) Party responsible for the claim #xD; priority S 0..1 CodeableConcept Desired processing urgency Binding: ProcessPriorityCodes (required) #xD; claim 1..1 Reference(Claim) Claim reference #xD; identifier 1..1 Identifier GFE identifier of the originally submitted claim #xD; system S 0..1 uri The namespace for the identifier value #xD; value 1..1 string The value that is unique #xD; insurance #xD; coverage 1..1 Reference(PCT Coverage) Insurance information #xD; item 1..* BackboneElement Product or service provided #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:serviceDescription SC 0..1 string Service Description URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription #xD; revenue 0..1 CodeableConcept Revenue or cost center code Binding: PCT GFE NUBC Revenue Value Set (required) #xD; productOrService 1..1 CodeableConcept Billing, service, product, or drug code Binding: Claim Medical Product or Service Value Set (required) #xD; coding <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( pct-cpt-display )">C 0..* Coding Code defined by a terminology system Constraints: pct-cpt-display #xD; modifier S 0..4 CodeableConcept Product or service billing modifiers Binding: PCT GFE Item CPT - HCPCS Value Set (required) #xD; coding <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( pct-cpt-display )">C 0..* Coding Code defined by a terminology system Constraints: pct-cpt-display #xD; serviced[x] 1..1 date, Period This is the planned or estimated date(s)s of service #xD; quantity S 0..1 SimpleQuantity(4.0.1) Count of products or services #xD; Slices for adjudication S 1..* BackboneElement Adjudication details Slice: Unordered, Open by value:category #xD; adjudication:All Slices Content/Rules for all slices #xD; category 1..1 CodeableConcept Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) #xD; adjudication:medicalmanagement S 0..* BackboneElement Adjudication details #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible) #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: medicalmanagement #xD; amount 0..0 #xD; value 0..0 #xD; adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only. #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) #xD; adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: adjustmentreason #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) #xD; adjudication:submitted S 0..1 BackboneElement Provider submitted amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: submitted #xD; adjudication:memberliability S 0..1 BackboneElement Member liability #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: memberliability #xD; adjudication:eligible S 0..1 BackboneElement Eligible amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: eligible #xD; adjudication:benefit S 0..1 BackboneElement Benefit amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: benefit #xD; Slices for adjudication S 0..* BackboneElement Header-level adjudication Slice: Unordered, Open by value:category #xD; adjudication:All Slices Content/Rules for all slices #xD; category 1..1 CodeableConcept Type of adjudication information Binding: PCT GFE Item Adjudication Value Set (extensible) #xD; adjudication:medicalmanagement S 0..* BackboneElement Header-level adjudication #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:subjectToMedicalMgmt 1..1 CodeableConcept Subject To Medical Management URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/subjectToMedicalMgmt Binding: Medical Management Type (extensible) #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: medicalmanagement #xD; amount 0..0 #xD; value 0..0 #xD; adjudication:billingnetworkstatus S 0..1 BackboneElement Billing Provider Network Status #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: billingnetworkstatus #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) #xD; adjudication:renderingnetworkstatus S 0..1 BackboneElement Rendering Provider Network Status #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: renderingnetworkstatus #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) #xD; adjudication:benefitpaymentstatus S 0..1 BackboneElement Benefit Payment Status #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: benefitpaymentstatus #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Payer Benefit Payment Status (required) #xD; adjudication:adjustmentreason S 0..* BackboneElement Adjustment Reason #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: adjustmentreason #xD; reason 0..1 CodeableConcept Explanation of adjudication outcome Binding: PCT Adjustment Reason (required) #xD; adjudication:submitted S 0..1 BackboneElement Provider submitted amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: submitted #xD; adjudication:memberliability S 0..1 BackboneElement Member liability #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: memberliability #xD; adjudication:eligible S 0..1 BackboneElement Eligible amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: eligible #xD; adjudication:benefit S 0..1 BackboneElement Benefit amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: benefit #xD; Slices for total 3..* BackboneElement Adjudication totals Slice: Unordered, Open by value:category #xD; total:All Slices Content/Rules for all slices #xD; category S 1..1 CodeableConcept Type of adjudication information Binding: PCT Total Value Set (extensible) #xD; total:submitted S 1..1 BackboneElement Total provider submitted amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: submitted #xD; total:memberliability S 1..1 BackboneElement Total member liability #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudicationCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: memberliability #xD; total:eligible S 1..1 BackboneElement Total eligible amount #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: eligible #xD; total:innetwork S 0..1 BackboneElement Total in network amount - only include when total type is applicable #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: innetwork #xD; total:outofnetwork S 0..1 BackboneElement Total out of network amount - only include when total type is applicable #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: outofnetwork #xD; total:noncovered S 0..1 BackboneElement Total noncovered amount - only include when total type is applicable #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTAdjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: noncovered #xD; total:negotiated S 0..1 BackboneElement Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTNetworkStatusCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: negotiated #xD; total:benefit S 0..1 BackboneElement Total benefit amount - only include when total type is applicable #xD; category 1..1 CodeableConcept Type of adjudication information Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: benefit #xD; processNote 1..* BackboneElement Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers. #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:processNoteClass 0..1 CodeableConcept ProcessNote Class URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/processNoteClass Binding: PCT AEOB Process Note Types (required) #xD; benefitPeriod 1..1 Period When the benefits are applicable #xD; <a href="StructureDefinition-davinci-pct-aeob-definitions.html#ExplanationOfBenefit.benefitBalance" title="Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.">benefitBalance 1..* BackboneElement Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. #xD; category 1..1 CodeableConcept Benefit classification Binding: PCT benefitBalance.category codes (required) #xD; text S 1..1 string Plain text representation of the concept #xD; unit 1..1 CodeableConcept Individual or family Binding: UnitTypeCodes (required) #xD; term 1..1 CodeableConcept Annual or lifetime Binding: BenefitTermCodes (required) #xD; financial 1..* BackboneElement Benefit Summary #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:remaining S 0..1 unsignedInt S, Money S Benefit Remaining URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/remaining-benefit #xD; type 1..1 CodeableConcept Benefit classification Binding: PCT Financial Type Value Set (required) #xD; allowed[x] S 1..1 Benefits allowed #xD; = 0)">allowedUnsignedInt unsignedInt S #xD; allowedMoney Money S #xD; used[x] S 1..1 Benefits used #xD; = 0)">usedUnsignedInt unsignedInt S #xD; usedMoney Money S #xD; Documentation for this format
HL7 International / Financial Management
The No Surprises Act requires that group health plans and insurers provide advance cost estimates, called advanced explanations of benefits (advanced EOBs), for scheduled services. This profile is used for exchanging the Advanced EOB data.
This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Advanced EOB: SHALL have serviceDescription at the item or header level (can be at both locations)
extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists() or item.extension.where(url='http://hl7.org/fhir/us/davinci-pct/StructureDefinition/serviceDescription').exists()
Advanced EOB: SHALL have adjudication[submitted] at the item or header level (can be at both locations)
adjudication.where(category.coding.where(code='submitted').exists()).exists() or item.adjudication.where(category.coding.where(code='submitted').exists()).exists()
Advanced EOB: SHALL have adjudication[memberliability] at the item or header level (can be at both locations)
adjudication.where(category.coding.where(code='memberliability').exists()).exists() or item.adjudication.where(category.coding.where(code='memberliability').exists()).exists()
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The GFE Bundle submitted by an entity that started the process for obtaining an Advanced EOB.
This extension is used to reference the GFE submitted by an entity that started the process for obtaining an Advanced EOB.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
This extension is used to communicate a plain language description of the procedure, product, or service.
This extension provides a payer link to information enabling the patient to find providers that are in network for the requested services.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this explanation of benefit.
Allows EOBs to be distinguished and referenced.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Identifier.system is always case sensitive.
There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](http://hl7.org/fhir/R4/extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.
Claim type determine the general sets of business rules applied for information requirements and adjudication.
A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
This may contain the local bill type codes such as the US UB-04 bill type code.
Some jurisdictions need a finer grained claim type for routing and adjudication.
claim | preauthorization | predetermination
A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
This element is required to understand the nature of the request for adjudication.
The recipient of the products and services
The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimbursement is sought.
The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
The period for which charges are being submitted.
Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.
A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
The date and time this estimate was calculated.
The date and time this estimate was calculated based on what was known at that point in time.
Need to record a timestamp for use by both the recipient and the issuer.
Individual who created the claim, predetermination or preauthorization.
Some jurisdictions require the contact information for personnel completing claims.
The party responsible for authorization, adjudication and reimbursement.
To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
The provider which is responsible for the claim, predetermination or preauthorization.
Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
A code to indicate whether and for whom funds are to be reserved for future claims.
This field is only used for preauthorizations.
In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.
For whom funds are to be reserved: (Patient, Provider, None).
A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
For example, for the original treatment and follow-up exams.
For workplace or other accidents it is common to relate separate claims arising from the same event.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A code to convey how the claims are related.
Some insurers need a declaration of the type of relationship.
Relationship of this claim to a related Claim.
An alternate organizational reference to the case or file to which this particular claim pertains.
For example, Property/Casualty insurer claim number or Workers Compensation case number.
In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
Prescription authorizing services or products
Prescription to support the dispensing of pharmacy, device or vision products.
Required to authorize the dispensing of controlled substances and devices.
Original prescription if superceded by fulfiller
Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
The party to be reimbursed for cost of the products and services according to the terms of the policy.
Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.
The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Type of Party to be reimbursed: Subscriber, provider, other.
Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Reference to the individual or organization to whom any payment will be made.
Not required if the payee is 'subscriber' or 'provider'.
Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
The referral resource which lists the date, practitioner, reason and other supporting information.
Some insurers require proof of referral to pay for services or to pay specialist rates for services.
Facility where the services were provided.
Insurance adjudication can be dependant on where services were delivered.
The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
To provide a link to the original adjudication request.
Literal reference, Relative, internal or absolute URL
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
GFE identifier of the originally submitted claim
Matches the provider submitted GFE claim.identifier this Advance ExplanationOfBenefit is addressing where identifier.type = http://terminology.hl7.org/CodeSystem/v2-0203|PLAC (with the identifier.value and identifier.system matching the original GFE identifier values).
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.
To provide a link to the original adjudication response.
The outcome of the claim, predetermination, or preauthorization processing.
The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
To advise the requestor of an overall processing outcome.
A human readable description of the status of the adjudication.
Reference from the Insurer which is used in later communications which refers to this adjudication.
This value is only present on preauthorization adjudications.
On subsequent claims, the insurer may require the provider to quote this value.
The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.
The members of the team who provided the products and services.
Common to identify the responsible and supporting practitioners.
A number to uniquely identify care team entries.
Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Member of the team who provided the product or service.
Often a regulatory requirement to specify the responsible provider.
The party who is billing and/or responsible for the claimed products or services.
Responsible might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the lead or responsible individual.
The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Role might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the roles performed by each member.
The role codes for the care team members.
Practitioner credential or specialization
The qualification of the practitioner which is applicable for this service.
Need to specify which qualification a provider is delivering the product or service under.
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Often there are multiple jurisdiction specific valuesets which are required.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
A number to uniquely identify supporting information entries.
Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Classification of the supplied information
The general class of the information supplied: information; exception; accident, employment; onset, etc.
This may contain a category for the local bill type codes.
Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
The valuset used for additional information category codes.
System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Required to identify the kind of additional information.
The valuset used for additional information codes.
The date when or period to which this information refers.
Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.
To convey the data content to be provided when the information is more than a simple code or period.
Provides the reason in the situation where a reason code is required in addition to the content.
For example: the reason for the additional stay, or why a tooth is missing.
Needed when the supporting information has both a date and amount/value and requires explanation.
Information about diagnoses relevant to the claim items.
Required for the adjudication by provided context for the services and product listed.
A number to uniquely identify diagnosis entries.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Provides health context for the evaluation of the products and/or services.
When the condition was observed or the relative ranking.
For example: admitting, primary, secondary, discharge.
Often required to capture a particular diagnosis, for example: primary or discharge.
The type of the diagnosis: admitting, principal, discharge.
Indication of whether the diagnosis was present on admission to a facility.
Many systems need to understand for adjudication if the diagnosis was present a time of admission.
A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
For example, DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
The DRG codes associated with the diagnosis.
Procedures performed on the patient relevant to the billing items with the claim.
The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
A number to uniquely identify procedure entries.
Necessary to provide a mechanism to link to claim details.
Date and optionally time the procedure was performed.
The code or reference to a Procedure resource which identifies the clinical intervention performed.
This identifies the actual clinical procedure.
Unique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
This indicates the relative order of a series of EOBs related to different coverages for the same suite of services.
Needed to coordinate between multiple EOBs for the same suite of services.
Financial instruments for reimbursement for the health care products and services specified on the claim.
All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
At least one insurer is required for a claim to be a claim.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example, a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
To identify which coverage in the list is being used to adjudicate this claim.
Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Required to allow the adjudicator to locate the correct policy and history within their information system.
Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Details of a accident which resulted in injuries which required the products and services listed in the claim.
When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.
Date of an accident event related to the products and services contained in the claim.
The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Required for audit purposes and adjudication.
The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Coverage may be dependant on the type of accident.
Type of accident: work place, auto, etc.
The physical location of the accident event.
Required for audit purposes and determination of applicable insurance liability.
A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
The items to be processed for adjudication.
A number to uniquely identify item entries.
Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Care team members related to this service or product.
Need to identify the individuals and their roles in the provision of the product or service.
Diagnoses applicable for this service or product.
Need to related the product or service to the associated diagnoses.
Procedures applicable for this service or product.
Need to provide any listed specific procedures to support the product or service being claimed.
Applicable exception and supporting information
Exceptions, special conditions and supporting information applicable for this service or product.
Need to reference the supporting information items that relate directly to this product or service.
The type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
Code to identify the general type of benefits under which products and services are provided.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Benefit categories such as: oral, medical, vision, oral-basic etc.
When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Necessary to state what was provided or done.
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
CPT codes require a display value (CPT Consumer Friendly Descriptors recommended)
system = 'http://www.ama-assn.org/go/cpt' implies display.exists()
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Item typification or modifiers codes to convey additional context for the product or service.
For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
To support inclusion of the item for adjudication or to charge an elevated fee.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
This is the planned or estimated date(s)s of service
This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication
Needed to determine whether the service or product was provided during the term of the insurance coverage.
Place of service or where product was supplied
Where the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
The number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
The amount charged to the patient by the provider for a single unit.
A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The quantity times the unit price for an additional service or product or charge.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Provides the total amount claimed for the group (if a grouper) or the line item.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
The code for the teeth, quadrant, sextant and arch.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
The code for the tooth surface and surface combinations.
A billed item may include goods or services provided in multiple encounters.
Used in some jurisdictions to link clinical events to claim items.
The numbers associated with notes below which apply to the adjudication of this item.
Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Needed to enable understanding of the context of the other information in the adjudication.
A code supporting the understanding of the adjudication result and explaining variance from expected amount.
For example, may indicate that the funds for this benefit type have been exhausted.
To support understanding of variance from adjudication expectations.
Monetary amount associated with the category.
For example, amount submitted, eligible amount, co-payment, and benefit payable.
Most adjuciation categories convey a monetary amount.
A non-monetary value associated with the category. Mutually exclusive to the amount element above.
For example: eligible percentage or co-payment percentage.
Some adjudication categories convey a percentage or a fixed value.
This extension is used to provide a reason to explain how the estimate may change subject to medical management.
Benefit Payment Status: Line level benefit payment status associated with professional claim estimates only.
Eligible is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.
Benefit is similar to allowed amount. Eligible amount and Benefit amount may be different or the same, but if they are different the payer can supply both for the full picture of the estimate.
A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Codes for the revenue or cost centers supplying the service and/or products.
Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
For example, in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
The first-tier service adjudications for payor added product or service lines.
Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Claim items which this service line is intended to replace.
The sequence number of the details within the claim item which this line is intended to replace.
Provides references to the claim details within the claim item.
The sequence number of the sub-details woithin the details within the claim item which this line is intended to replace.
Provides references to the claim sub-details within the claim detail.
The providers who are authorized for the services rendered to the patient.
Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
The second-tier service adjudications for payor added services.
The third-tier service adjudications for payor added services.
The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Categorized monetary totals for the adjudication.
Totals for amounts submitted, co-pays, benefits payable etc.
To provide the requestor with financial totals by category for the adjudication.
A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Needed to convey the type of total provided.
Monetary total amount associated with the category.
Needed to convey the total monetary amount.
Total in network amount - only include when total type is applicable
Total out of network amount - only include when total type is applicable
Total noncovered amount - only include when total type is applicable
Total negotiated amount - Total for special negotiated status for a service or product in relation to a patient's coverage that is established outside of a formal network contract
Total benefit amount - only include when total type is applicable
Payment details for the adjudication of the claim.
Needed to convey references to the financial instrument that has been used if payment has been made.
Whether this represents partial or complete payment of the benefits payable.
To advise the requestor when the insurer believes all payments to have been completed.
The type (partial, complete) of the payment.
Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
To advise the requestor of adjustments applied to the payment.
Needed to clarify the monetary adjustment.
Estimated date the payment will be issued or the actual issue date of payment.
To advise the payee when payment can be expected.
Benefits payable less any payment adjustment.
Needed to provide the actual payment amount.
Issuer's unique identifier for the payment instrument.
For example: EFT number or check number.
Enable the receiver to reconcile when payment received.
A code for the form to be used for printing the content.
May be needed to identify specific jurisdictional forms.
Needed to specify the specific form used for producing output for this response.
The actual form, by reference or inclusion, for printing the content or an EOB.
Needed to permit insurers to include the actual form.
Needed to include the specific form used for producing output for this response.
Disclaimers go here. Notes should be clear and as specific to the situation at hand as possible including any additional assumptions and requirements. This may include notes about prior authorization, out of network providers, benefit period, and other legal or otherwise required disclaimers.
A note that describes or explains adjudication results in a human readable form.
These disclaimers may include, but are not limited to things such as: notes on prior authorization or other medical management requirements, provider discounts, limitations, preconditions, assumptions, information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
Provides the insurer specific textual explanations associated with the processing.
This extension is used to indicate a the class of AEOB Claim process notes
A number to uniquely identify a note entry.
Necessary to provide a mechanism to link from adjudications.
To convey the expectation for when the text is used.
The explanation or description associated with the processing.
Required to provide human readable explanation.
A code to define the language used in the text of the note.
Only required if the language is different from the resource language.
Note text may vary from the resource defined language.
The term of the benefits documented in this response.
Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.
Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied.
Estimated Balance by Benefit Category as if the expected item(s) or service(s) included in this estimate were applied. Note: The available balance is based on known claims and does not account for other Good Faith Estimates (GFEs). Benefit balances will remain unchanged until the claim adjudication process applies benefits. Consequently, if multiple estimates pertain to the same benefit, the benefit balance will not consider other estimates.
Needed to convey the category of service or product for which eligibility is sought.
True if the indicated class of service is excluded from the plan, missing or False indicates the product or service is included in the coverage.
Needed to identify items that are specifically excluded from the coverage.
Required to align with other plan names.
Description of the benefit or services covered
A richer description of the benefit or services covered.
For example, 'DENT2 covers 100% of basic, 50% of major but excludes Ortho, Implants and Cosmetic services'.
Is a flag to indicate whether the benefits refer to in-network providers or out-of-network providers.
Needed as in or out of network providers are treated differently under the coverage.
Code to classify in or out of network services.
Indicates if the benefits apply to an individual or to the family.
Needed for the understanding of the benefits.
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
The quantity of the benefit remaining to date.
Classification of benefit being provided.
For example: deductible, visits, benefit amount.
Needed to convey the nature of the benefit.
The quantity of the benefit which is permitted under the coverage.
Needed to convey the benefits offered under the coverage.
The quantity of the benefit which have been consumed to date.
Needed to convey the benefits consumed to date.