Generated Narrative: StructureDefinition profile-ExplanationOfBenefit Name Flags Card. Type Description & Constraints ExplanationOfBenefit 0..* ExplanationOfBenefit Explanation of Benefit resource #xD; Slices for extension 2..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:use 1..1 code R4: claim | preauthorization | predetermination (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.use Binding: Use (required): Complete, proposed, exploratory, other. #xD; extension:provider 1..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: Party responsible for the claim URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; extension:priority 0..1 CodeableConcept R4: Desired processing urgency (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.priority #xD; extension:fundsReserveRequested 0..1 CodeableConcept R4: For whom to reserve funds (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.fundsReserveRequested Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). #xD; extension:fundsReserve 0..1 CodeableConcept R4: Funds reserved status (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.fundsReserve Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). #xD; extension:preAuthRef 0..* string R4: Preauthorization reference (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.preAuthRef #xD; extension:preAuthRefPeriod 0..* Period R4: Preauthorization in-effect period (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.preAuthRefPeriod #xD; extension:adjudication 0..* (Complex) R4: Header-level adjudication (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.item.adjudication #xD; extension:total 0..* (Complex) R4: Adjudication totals (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.total #xD; extension:benefitPeriod 0..1 Period R4: When the benefits are applicable (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.benefitPeriod #xD; enterer #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:enterer 0..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: Author of the claim additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; referral #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:referral 0..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: referral additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; outcome #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:outcome 1..1 code R4: queued | complete | error | partial URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.outcome Binding: R4RemittanceOutcomeForR3 (0.1.0) (required): The result of the claim processing. #xD; payee #xD; party #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:party 0..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: Recipient reference URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; information #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:value 0..1 boolean R4: Data to be provided additional types URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.supportingInfo.value #xD; careTeam #xD; provider #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:provider 0..1 ?gen-e1? [CanonicalType[http://hl7.org/fhir/StructureDefinition/alternate-reference]] R4: Practitioner or organization URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; diagnosis #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:onAdmission 0..1 CodeableConcept R4: Present on admission (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.diagnosis.onAdmission Binding: R4ExDiagnosisOnAdmissionForR3 (0.1.0) (example): Present on admission. #xD; procedure #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:type 0..* CodeableConcept R4: Category of Procedure (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.procedure.type Binding: R4ExProcedureTypeForR3 (0.1.0) (example): Example procedure type codes. #xD; extension:udi 0..* Reference(Cross-version Profile for R4.Device for use in FHIR STU3(0.1.0) | Device) R4: Unique device identifier (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.procedure.udi #xD; insurance #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:focal 1..1 boolean R4: Coverage to be used for adjudication (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.insurance.focal #xD; addItem #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:detailSequence 0..* positiveInt R4: Detail sequence number (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detailSequence #xD; extension:subDetailSequence 0..* positiveInt R4: Subdetail sequence number (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.subDetailSequence #xD; extension:provider 0..* Reference(Cross-version Profile for R4.Practitioner for use in FHIR STU3(0.1.0) | Practitioner | Cross-version Profile for R4.PractitionerRole for use in FHIR STU3(0.1.0) | PractitionerRole | Cross-version Profile for R4.Organization for use in FHIR STU3(0.1.0) | Organization) R4: Authorized providers (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.provider #xD; extension:programCode 0..* CodeableConcept R4: Program the product or service is provided under (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.programCode Binding: Example Program Reason Codes (example): Program specific reason codes. #xD; extension:serviced 0..1 date, Period R4: Date or dates of service or product delivery (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.serviced #xD; extension:location 0..1 CodeableConcept, Address, Reference(Cross-version Profile for R4.Location for use in FHIR STU3(0.1.0) | Location) R4: Place of service or where product was supplied (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.location Binding: Example Service Place Codes (example): Place where the service is rendered. #xD; extension:quantity 0..1 SimpleQuantity R4: Count of products or services (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.quantity #xD; extension:unitPrice 0..1 Money R4: Fee, charge or cost per item (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.unitPrice #xD; extension:factor 0..1 decimal R4: Price scaling factor (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.factor #xD; extension:bodySite 0..1 CodeableConcept R4: Anatomical location (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.bodySite Binding: Oral Site Codes (example): The code for the teeth, quadrant, sextant and arch. #xD; extension:subSite 0..* CodeableConcept R4: Anatomical sub-location (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.subSite Binding: Surface Codes (example): The code for the tooth surface and surface combinations. #xD; detail #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:quantity 0..1 SimpleQuantity R4: Count of products or services (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.quantity #xD; extension:unitPrice 0..1 Money R4: Fee, charge or cost per item (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.unitPrice #xD; extension:factor 0..1 decimal R4: Price scaling factor (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.factor #xD; extension:subDetail 0..* (Complex) R4: Insurer added line items (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail #xD; extension:adjudication 0..* (Complex) R4: Added items adjudication (new) URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.item.adjudication #xD; form #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:form 0..1 Attachment R4: Printed reference or actual form additional types URL: http://hl7.org/fhir/4.0/StructureDefinition/extension-ExplanationOfBenefit.form #xD; Documentation for this format
Cross-version Profile for R4.ExplanationOfBenefit for use in FHIR STU3
This cross-version profile allows R4 ExplanationOfBenefit content to be represented via FHIR STU3 ExplanationOfBenefit resources.
Canadian Dental Association eclaims standard
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 NOT contain any narrative
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 the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty()
not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
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 may not always be associated with version changes to the resource.
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.
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. This element is labelled 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 may 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 in formation 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.
R4: claim | preauthorization | predetermination (new)
R4: `ExplanationOfBenefit.use` (new:code)
Element `ExplanationOfBenefit.use` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.use` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Element `ExplanationOfBenefit.provider` is mapped to FHIR STU3 element `ExplanationOfBenefit.provider` as `SourceIsBroaderThanTarget`. Element `ExplanationOfBenefit.provider` is mapped to FHIR STU3 element `ExplanationOfBenefit.organization` as `SourceIsBroaderThanTarget`. The standard extension `alternate-reference` has been mapped as the representation of FHIR R4 element `ExplanationOfBenefit.provider` with unmapped reference targets: PractitionerRole. 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.
R4: `ExplanationOfBenefit.priority` (new:CodeableConcept)
Element `ExplanationOfBenefit.priority` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.priority` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). 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.
R4: `ExplanationOfBenefit.fundsReserveRequested` (new:CodeableConcept)
Element `ExplanationOfBenefit.fundsReserveRequested` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.fundsReserveRequested` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This field is only used for preauthorizations.
R4: `ExplanationOfBenefit.fundsReserve` (new:CodeableConcept)
Element `ExplanationOfBenefit.fundsReserve` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.fundsReserve` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
R4: `ExplanationOfBenefit.preAuthRef` (new:string)
Element `ExplanationOfBenefit.preAuthRef` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.preAuthRef` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This value is only present on preauthorization adjudications.
R4: Preauthorization in-effect period (new)
R4: `ExplanationOfBenefit.preAuthRefPeriod` (new:Period)
Element `ExplanationOfBenefit.preAuthRefPeriod` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.preAuthRefPeriod` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This value is only present on preauthorization adjudications.
R4: `ExplanationOfBenefit.adjudication` (new:ExplanationOfBenefit.item.adjudication)
Element `ExplanationOfBenefit.adjudication` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.adjudication` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.total` (new:BackboneElement)
Element `ExplanationOfBenefit.total` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.total` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). Totals for amounts submitted, co-pays, benefits payable etc.
R4: When the benefits are applicable (new)
R4: `ExplanationOfBenefit.benefitPeriod` (new:Period)
Element `ExplanationOfBenefit.benefitPeriod` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.benefitPeriod` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). Not applicable when use=claim.
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. Usually modifier elements provide negation or qualification. In order 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.
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.
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.
A code specifying the state of the resource instance.
The category of claim, eg, oral, pharmacy, vision, insitutional, professional.
Affects which fields and value sets are used.
The type or discipline-style of the claim
A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.
This may contain the local bill type codes such as the US UB-04 bill type code.
The subject of the Products and Services
The billable period for which charges are being submitted.
The person who created the explanation of benefit.
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
R4: Author of the claim additional types
R4: `ExplanationOfBenefit.enterer` additional types from child elements (display, identifier, reference, type)
Element `ExplanationOfBenefit.enterer` is mapped to FHIR STU3 element `ExplanationOfBenefit.enterer` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.enterer` do not cover the following types based on type expansion: display, identifier, reference, type. The standard extension `alternate-reference` has been mapped as the representation of FHIR R4 element `ExplanationOfBenefit.enterer` with unmapped reference targets: PractitionerRole.
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.
Logical reference, when literal reference is not known
An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
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.
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 insurer which is responsible for the explanation of benefit.
The provider which is responsible for the claim.
The referral resource which lists the date, practitioner, reason and other supporting information.
R4: `ExplanationOfBenefit.referral` additional types from child elements (display, identifier, reference, type)
Element `ExplanationOfBenefit.referral` is mapped to FHIR STU3 element `ExplanationOfBenefit.referral` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.referral` do not cover the following types based on type expansion: display, identifier, reference, type. The standard extension `alternate-reference` has been mapped as the representation of FHIR R4 element `ExplanationOfBenefit.referral` with unmapped reference targets: ServiceRequest. The referral resource which lists the date, practitioner, reason and other supporting information.
Facility where the services were provided.
The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.
Processing outcome errror, partial or complete processing.
Element `ExplanationOfBenefit.outcome` is mapped to FHIR STU3 element `ExplanationOfBenefit.outcome` as `RelatedTo`. 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).
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 translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
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
A description of the status of the adjudication.
Related Claims which may be revelant to processing this claim
Other claims which are related to this claim such as prior claim versions or for related services.
Additional Content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. In order 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.
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.
Relationship of this claim to a related Claim
An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .
Prescription authorizing services or products
Prescription to support the dispensing of Pharmacy or Vision products.
Original prescription if superceded by fulfiller
Original prescription which has been superceded 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 precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
The party to be reimbursed for the services.
Type of party: Subscriber, Provider, other
Type of Party to be reimbursed: Subscriber, provider, other.
organization | patient | practitioner | relatedperson
organization | patient | practitioner | relatedperson.
Party to be reimbursed: Subscriber, provider, other.
Element `ExplanationOfBenefit.payee.party` is mapped to FHIR STU3 element `ExplanationOfBenefit.payee.party` as `SourceIsBroaderThanTarget`. The standard extension `alternate-reference` has been mapped as the representation of FHIR R4 element `ExplanationOfBenefit.payee.party` with unmapped reference targets: PractitionerRole. Not required if the payee is 'subscriber' or 'provider'.
Exceptions, special considerations, the condition, situation, prior or concurrent issues
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
R4: Data to be provided additional types
R4: `ExplanationOfBenefit.supportingInfo.value[x]` additional types (boolean)
Element `ExplanationOfBenefit.supportingInfo.value[x]` is mapped to FHIR STU3 element `ExplanationOfBenefit.information.value[x]` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.supportingInfo.value[x]` do not cover the following types: boolean. The target context `ExplanationOfBenefit.information.value[x]` is a choice-type element and cannot directly hold extensions. The context is moved up to parent element `ExplanationOfBenefit.information`. 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.
Sequence of the information element which serves to provide a link.
The general class of the information supplied: information; exception; accident, employment; onset, etc.
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 which may influence the adjudication.
The valuset used for additional information codes.
The date when or period to which this information refers.
Additional Data or supporting information
Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.
The members of the team who provided the overall service as well as their role and whether responsible and qualifications.
Role and Responsible may not be required when there is only a single provider listed.
Sequence of careteam which serves to order and provide a link.
Required to maintain order of the careteam members.
The members of the team who provided the overall service.
R4: `ExplanationOfBenefit.careTeam.provider`
Element `ExplanationOfBenefit.careTeam.provider` is mapped to FHIR STU3 element `ExplanationOfBenefit.careTeam.provider` as `SourceIsBroaderThanTarget`. The standard extension `alternate-reference` has been mapped as the representation of FHIR R4 element `ExplanationOfBenefit.careTeam.provider` with unmapped reference targets: PractitionerRole.
The practitioner who is billing and responsible for the claimed services rendered to the patient.
The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.
The role codes for the care team members.
The qualification which is applicable for this service.
Ordered list of patient diagnosis for which care is sought.
R4: `ExplanationOfBenefit.diagnosis.onAdmission` (new:CodeableConcept)
Element `ExplanationOfBenefit.diagnosis.onAdmission` has a context of ExplanationOfBenefit.diagnosis based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.diagnosis.onAdmission` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
Sequence of diagnosis which serves to provide a link.
Required to allow line items to reference the diagnoses.
Required to adjudicate services rendered to condition presented.
The type of the Diagnosis, for example: admitting, primary, secondary, discharge.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Required to adjudicate services rendered to the mandated diagnosis grouping system.
The type of the diagnosis: admitting, principal, discharge
The package billing code, for example DRG, based on the assigned grouping code system.
Required to adjudicate services rendered to the mandated grouping system.
The DRG codes associated with the diagnosis
Ordered list of patient procedures performed to support the adjudication.
R4: `ExplanationOfBenefit.procedure.type` (new:CodeableConcept)
Element `ExplanationOfBenefit.procedure.type` has a context of ExplanationOfBenefit.procedure based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.procedure.type` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.procedure.udi` (new:Reference(Device))
Element `ExplanationOfBenefit.procedure.udi` has a context of ExplanationOfBenefit.procedure based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.procedure.udi` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
Sequence of procedures which serves to order and provide a link.
Required to maintain order of the procudures.
Date and optionally time the procedure was performed .
Required to adjudicate services rendered.
Health care programs and insurers are significant payors of health service costs.
Financial instrument by which payment information for health care.
R4: Coverage to be used for adjudication (new)
R4: `ExplanationOfBenefit.insurance.focal` (new:boolean)
Element `ExplanationOfBenefit.insurance.focal` has a context of ExplanationOfBenefit.insurance based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.insurance.focal` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). 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.
Reference to the program or plan identification, underwriter or payor.
Need to identify the issuer to target for processing and for coordination of benefit processing.
Pre-Authorization/Determination Reference
A list of references from the Insurer to which these services pertain.
To provide any pre=determination or prior authorization reference.
An accident which resulted in the need for healthcare services.
Date of an accident which these services are addressing.
Coverage may be dependant on the type of accident.
Type of accident: work place, auto, etc.
The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).
The start and optional end dates of when the patient was confined to a treatment center.
Careteam applicable for this service or product line.
Diagnosis applicable for this service or product line.
Procedures applicable for this service or product line.
Applicable exception and supporting information
Exceptions, special conditions and supporting information pplicable for this service or product line.
The type of reveneu or cost center providing the product and/or service.
Codes for the revenue or cost centers supplying the service and/or products.
Health Care Service Type Codes to identify the classification of service or benefits.
Benefit subcategories such as: oral-basic, major, glasses
If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.
Item typification or modifiers codes, eg for 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.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program specific reason for item inclusion
For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.
The date or dates when the enclosed suite of services were performed or completed.
The number of repetitions of a service or product.
If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.
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.
If a fee is present the associated product/service code must be present.
The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.
List of Unique Device Identifiers associated with this line item.
The UDI code and issuer if applicable for the supplied product.
Physical service site on the patient (limb, tooth, etc).
The code for the teeth, quadrant, sextant and arch
A region or surface of the site, eg. 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.
A list of note references to the notes provided below.
Adjudication category such as co-pay, eligible, benefit, etc.
Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.
Adjudication reason such as limit reached.
Monitory amount associated with the code.
A non-monetary value for example a percentage. Mutually exclusive to the amount element above.
Service, Product, Rx Dispense, Rx Compound etc.
A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).
The fee for an addittional service or product or charge.
The first tier service adjudications for payor added services.
R4: `ExplanationOfBenefit.addItem.detailSequence` (new:positiveInt)
Element `ExplanationOfBenefit.addItem.detailSequence` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detailSequence` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.subDetailSequence` (new:positiveInt)
Element `ExplanationOfBenefit.addItem.subDetailSequence` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.subDetailSequence` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.provider` (new:Reference(Practitioner,PractitionerRole,Organization))
Element `ExplanationOfBenefit.addItem.provider` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.provider` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: Program the product or service is provided under (new)
R4: `ExplanationOfBenefit.addItem.programCode` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.programCode` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.programCode` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). For example: Neonatal program, child dental program or drug users recovery program.
R4: Date or dates of service or product delivery (new)
R4: `ExplanationOfBenefit.addItem.serviced[x]` (new:date, Period)
Element `ExplanationOfBenefit.addItem.serviced[x]` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.serviced[x]` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: Place of service or where product was supplied (new)
R4: `ExplanationOfBenefit.addItem.location[x]` (new:Address, CodeableConcept, Reference(Location))
Element `ExplanationOfBenefit.addItem.location[x]` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.location[x]` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.quantity` (new:Quantity[SimpleQuantity])
Element `ExplanationOfBenefit.addItem.quantity` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.quantity` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.unitPrice` (new:Money)
Element `ExplanationOfBenefit.addItem.unitPrice` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.unitPrice` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.factor` (new:decimal)
Element `ExplanationOfBenefit.addItem.factor` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.factor` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
R4: `ExplanationOfBenefit.addItem.bodySite` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.bodySite` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.bodySite` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
R4: `ExplanationOfBenefit.addItem.subSite` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.subSite` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.subSite` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
List of input service items which this service line is intended to replace.
The fee charged for the professional service or product.
The second tier service adjudications for payor added services.
R4: `ExplanationOfBenefit.addItem.detail.quantity` (new:Quantity[SimpleQuantity])
Element `ExplanationOfBenefit.addItem.detail.quantity` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.quantity` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.detail.unitPrice` (new:Money)
Element `ExplanationOfBenefit.addItem.detail.unitPrice` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.unitPrice` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.detail.factor` (new:decimal)
Element `ExplanationOfBenefit.addItem.detail.factor` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.factor` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
R4: `ExplanationOfBenefit.addItem.detail.subDetail` (new:BackboneElement)
Element `ExplanationOfBenefit.addItem.detail.subDetail` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
R4: `ExplanationOfBenefit.addItem.detail.subDetail.adjudication` (new:ExplanationOfBenefit.item.adjudication)
Element `ExplanationOfBenefit.addItem.detail.subDetail.adjudication` is part of an existing definition because parent element `ExplanationOfBenefit.addItem.detail.subDetail` requires a cross-version extension. Element `ExplanationOfBenefit.addItem.detail.subDetail.adjudication` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.adjudication` has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).
The total cost of the services reported.
This is a check value that the receiver calculates and returns.
The amount of deductable applied which was not allocated to any particular service line.
Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).
Payment details for the claim if the claim has been paid.
Whether this represents partial or complete payment of the claim.
The type (partial, complete) of the payment
Adjustment to the payment of this transaction which is not related to adjudication of this transaction.
Explanation for the non-claim adjustment
The form to be used for printing the content.
R4: Printed reference or actual form additional types
R4: `ExplanationOfBenefit.form` additional types (Attachment) additional types from child elements (creation, data, hash, size, title, url)
Element `ExplanationOfBenefit.form` is mapped to FHIR STU3 element `ExplanationOfBenefit.form` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.form` do not cover the following types: Attachment. The mappings for `ExplanationOfBenefit.form` do not cover the following types based on type expansion: creation, data, hash, size, title, url. Needed to permit insurers to include the actual form.
An integer associated with each note which may be referred to from each service line item.
The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.
Dental, Vision, Medical, Pharmacy, Rehab etc.
Benefit categories such as: oral, medical, vision etc.
Detailed services covered within the type
Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.
True if the indicated class of service is excluded from the plan, missing or False indicated the service is included in the coverage.
A short name or tag for the benefit, for example MED01, or DENT2.
Description of the benefit or services covered
A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.
Code to classify in or out of network services
Unit covered/serviced - individual or family
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.