Generated Narrative: StructureDefinition profile-ExplanationOfBenefit Name Flags Card. Type Description & Constraints ExplanationOfBenefit 0..* ExplanationOfBenefit(4.0.1) Explanation of Benefit resource #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.traceNumber #xD; extension:event 0..* (Complex) R5: Event information (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.event #xD; extension:encounter 0..* Reference(Cross-version Profile for R5.Encounter for use in FHIR R4(0.1.0) | Encounter) R5: Encounters associated with the listed treatments (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.encounter #xD; extension:decision 0..1 CodeableConcept R5: Result of the adjudication (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.decision Binding: R5ClaimDecisionForR4 (0.1.0) (example) #xD; extension:diagnosisRelatedGroup 0..1 CodeableConcept R5: Package billing code (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.diagnosisRelatedGroup Binding: ExampleDiagnosisRelatedGroupCodes (example) #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.patientPaid #xD; enterer #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:enterer 0..1 Reference(Resource) R5: enterer URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; facility #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:facility 0..1 Reference(Resource) R5: facility additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; supportingInfo #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:value 0..1 Identifier R5: value additional types URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.supportingInfo.value #xD; item #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.traceNumber #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:request 0..* Reference(Cross-version Profile for R5.DeviceRequest for use in FHIR R4(0.1.0) | DeviceRequest | Cross-version Profile for R5.MedicationRequest for use in FHIR R4(0.1.0) | MedicationRequest | Cross-version Profile for R5.NutritionOrder for use in FHIR R4(0.1.0) | NutritionOrder | Cross-version Profile for R5.ServiceRequest for use in FHIR R4(0.1.0) | ServiceRequest | Cross-version Profile for R5.SupplyRequest for use in FHIR R4(0.1.0) | SupplyRequest | Cross-version Profile for R5.VisionPrescription for use in FHIR R4(0.1.0) | VisionPrescription) R5: Request or Referral for Service (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.request #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; adjudication #xD; value #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:quantity 0..1 Quantity R5: quantity additional types URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.adjudication.quantity #xD; detail #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.traceNumber #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Detail level adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; subDetail #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.subDetail.traceNumber #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.subDetail.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.detail.subDetail.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Subdetail level adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; addItem #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.traceNumber #xD; extension:revenue 0..1 CodeableConcept R5: Revenue or cost center code (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.revenue Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:request 0..* Reference(Cross-version Profile for R5.DeviceRequest for use in FHIR R4(0.1.0) | DeviceRequest | Cross-version Profile for R5.MedicationRequest for use in FHIR R4(0.1.0) | MedicationRequest | Cross-version Profile for R5.NutritionOrder for use in FHIR R4(0.1.0) | NutritionOrder | Cross-version Profile for R5.ServiceRequest for use in FHIR R4(0.1.0) | ServiceRequest | Cross-version Profile for R5.SupplyRequest for use in FHIR R4(0.1.0) | SupplyRequest | Cross-version Profile for R5.VisionPrescription for use in FHIR R4(0.1.0) | VisionPrescription) R5: Request or Referral for Service (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.request #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Additem level adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; bodySite #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:site 1..* (Complex) R5: Location (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.bodySite.site #xD; extension:subSite 0..* CodeableConcept R5: Sub-location (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.bodySite.subSite Binding: SurfaceCodes (example) #xD; detail #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.traceNumber #xD; extension:revenue 0..1 CodeableConcept R5: Revenue or cost center code (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.revenue Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Additem detail level adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; subDetail #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier R5: Number for tracking (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail.traceNumber #xD; extension:revenue 0..1 CodeableConcept R5: Revenue or cost center code (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail.revenue Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. #xD; extension:productOrServiceEnd 0..1 CodeableConcept R5: End of a range of codes (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd Binding: USCLSCodes (example) #xD; extension:patientPaid 0..1 Money R5: Paid by the patient (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail.patientPaid #xD; extension:tax 0..1 Money R5: Total tax (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.addItem.detail.subDetail.tax #xD; extension:reviewOutcome 0..1 (Complex) R5: Additem subdetail level adjudication results (new) URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.item.reviewOutcome #xD; processNote #xD; type #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:type 0..1 CodeableConcept R5: Note purpose additional types URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-ExplanationOfBenefit.processNote.type Binding: NoteType (extensible): The presentation types of notes. #xD; Documentation for this format
Cross-version Profile for R5.ExplanationOfBenefit for use in FHIR R4
This cross-version profile allows R5 ExplanationOfBenefit content to be represented via FHIR R4 ExplanationOfBenefit resources.
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
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")])
R5: `ExplanationOfBenefit.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.traceNumber` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
R5: `ExplanationOfBenefit.event` (new:BackboneElement)
Element `ExplanationOfBenefit.event` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.event` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Encounters associated with the listed treatments (new)
R5: `ExplanationOfBenefit.encounter` (new:Reference(Encounter))
Element `ExplanationOfBenefit.encounter` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.encounter` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.decision` (new:CodeableConcept)
Element `ExplanationOfBenefit.decision` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.decision` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element). The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).
R5: `ExplanationOfBenefit.diagnosisRelatedGroup` (new:CodeableConcept)
Element `ExplanationOfBenefit.diagnosisRelatedGroup` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.diagnosisRelatedGroup` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element). For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be 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.
R5: `ExplanationOfBenefit.patientPaid` (new:Money)
Element `ExplanationOfBenefit.patientPaid` has a context of ExplanationOfBenefit based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
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.
The type or discipline-style of the claim.
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.
This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
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.
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
Element `ExplanationOfBenefit.enterer` is mapped to FHIR R4 element `ExplanationOfBenefit.enterer` as `SourceIsBroaderThanTarget`. The standard extension `alternate-reference` has been mapped as the representation of FHIR R5 element `ExplanationOfBenefit.enterer` with unmapped reference targets: Patient, RelatedPerson.
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).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents 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. 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 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.
The timeliness with which processing is required: stat, normal, deferred.
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.
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.
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.
R5: `ExplanationOfBenefit.facility` additional types from child elements (display, identifier, reference, type)
Element `ExplanationOfBenefit.facility` is mapped to FHIR R4 element `ExplanationOfBenefit.facility` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.facility` 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 R5 element `ExplanationOfBenefit.facility` with unmapped reference targets: Organization.
The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.
To provide a link to the original adjudication request.
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.
R5: `ExplanationOfBenefit.supportingInfo.value[x]` additional types (Identifier)
Element `ExplanationOfBenefit.supportingInfo.value[x]` is mapped to FHIR R4 element `ExplanationOfBenefit.supportingInfo.value[x]` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.supportingInfo.value[x]` do not cover the following types: Identifier. The target context `ExplanationOfBenefit.supportingInfo.value[x]` is a choice-type element and cannot directly hold extensions. The context is moved up to parent element `ExplanationOfBenefit.supportingInfo`. 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.
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.
R5: `ExplanationOfBenefit.item.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.item.traceNumber` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.item.productOrServiceEnd` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Request or Referral for Service (new)
R5: `ExplanationOfBenefit.item.request` (new:Reference(DeviceRequest,MedicationRequest,NutritionOrder,ServiceRequest,SupplyRequest,VisionPrescription))
Element `ExplanationOfBenefit.item.request` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.request` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.patientPaid` (new:Money)
Element `ExplanationOfBenefit.item.patientPaid` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.tax` (new:Money)
Element `ExplanationOfBenefit.item.tax` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.reviewOutcome` (new:BackboneElement)
Element `ExplanationOfBenefit.item.reviewOutcome` has a context of ExplanationOfBenefit.item based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
Codes for the revenue or cost centers supplying the service and/or products.
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.
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.
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 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.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
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.
unique id for the element within a resource (for internal references)
R5: `ExplanationOfBenefit.item.adjudication.quantity` additional types (Quantity) additional types from child elements (code, comparator, system, unit)
Element `ExplanationOfBenefit.item.adjudication.quantity` is mapped to FHIR R4 element `ExplanationOfBenefit.item.adjudication.value` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.item.adjudication.quantity` do not cover the following types: Quantity. The mappings for `ExplanationOfBenefit.item.adjudication.quantity` do not cover the following types based on type expansion: code, comparator, system, unit. For example: eligible percentage or co-payment percentage.
R5: `ExplanationOfBenefit.item.detail.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.item.detail.traceNumber` has a context of ExplanationOfBenefit.item.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.item.detail.productOrServiceEnd` has a context of ExplanationOfBenefit.item.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.patientPaid` (new:Money)
Element `ExplanationOfBenefit.item.detail.patientPaid` has a context of ExplanationOfBenefit.item.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.tax` (new:Money)
Element `ExplanationOfBenefit.item.detail.tax` has a context of ExplanationOfBenefit.item.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Detail level adjudication results (new)
R5: `ExplanationOfBenefit.item.detail.reviewOutcome` (new:ExplanationOfBenefit.item.reviewOutcome)
Element `ExplanationOfBenefit.item.detail.reviewOutcome` has a context of ExplanationOfBenefit.item.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Examples include: Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
R5: `ExplanationOfBenefit.item.detail.subDetail.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.item.detail.subDetail.traceNumber` has a context of ExplanationOfBenefit.item.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.subDetail.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd` has a context of ExplanationOfBenefit.item.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.subDetail.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.subDetail.patientPaid` (new:Money)
Element `ExplanationOfBenefit.item.detail.subDetail.patientPaid` has a context of ExplanationOfBenefit.item.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.subDetail.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.item.detail.subDetail.tax` (new:Money)
Element `ExplanationOfBenefit.item.detail.subDetail.tax` has a context of ExplanationOfBenefit.item.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.subDetail.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Subdetail level adjudication results (new)
R5: `ExplanationOfBenefit.item.detail.subDetail.reviewOutcome` (new:ExplanationOfBenefit.item.reviewOutcome)
Element `ExplanationOfBenefit.item.detail.subDetail.reviewOutcome` has a context of ExplanationOfBenefit.item.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.item.detail.subDetail.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
R5: `ExplanationOfBenefit.addItem.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.addItem.traceNumber` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.revenue` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.revenue` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.revenue` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.productOrServiceEnd` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.request` (new:Reference(DeviceRequest,MedicationRequest,NutritionOrder,ServiceRequest,SupplyRequest,VisionPrescription))
Element `ExplanationOfBenefit.addItem.request` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.request` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.patientPaid` (new:Money)
Element `ExplanationOfBenefit.addItem.patientPaid` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.tax` (new:Money)
Element `ExplanationOfBenefit.addItem.tax` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Additem level adjudication results (new)
R5: `ExplanationOfBenefit.addItem.reviewOutcome` (new:ExplanationOfBenefit.item.reviewOutcome)
Element `ExplanationOfBenefit.addItem.reviewOutcome` has a context of ExplanationOfBenefit.addItem based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
For example, providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
R5: `ExplanationOfBenefit.addItem.bodySite.site` (new:CodeableReference(BodyStructure))
Element `ExplanationOfBenefit.addItem.bodySite.site` has a context of ExplanationOfBenefit.addItem.bodySite based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.bodySite.site` has no mapping targets in FHIR R4. 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.
R5: `ExplanationOfBenefit.addItem.bodySite.subSite` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.bodySite.subSite` has a context of ExplanationOfBenefit.addItem.bodySite based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.bodySite.subSite` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
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
The second-tier service adjudications for payor added services.
R5: `ExplanationOfBenefit.addItem.detail.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.addItem.detail.traceNumber` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.revenue` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.detail.revenue` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.revenue` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.detail.productOrServiceEnd` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.patientPaid` (new:Money)
Element `ExplanationOfBenefit.addItem.detail.patientPaid` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.tax` (new:Money)
Element `ExplanationOfBenefit.addItem.detail.tax` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Additem detail level adjudication results (new)
R5: `ExplanationOfBenefit.addItem.detail.reviewOutcome` (new:ExplanationOfBenefit.item.reviewOutcome)
Element `ExplanationOfBenefit.addItem.detail.reviewOutcome` has a context of ExplanationOfBenefit.addItem.detail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
The third-tier service adjudications for payor added services.
R5: `ExplanationOfBenefit.addItem.detail.subDetail.traceNumber` (new:Identifier)
Element `ExplanationOfBenefit.addItem.detail.subDetail.traceNumber` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.traceNumber` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.subDetail.revenue` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.detail.subDetail.revenue` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.revenue` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd` (new:CodeableConcept)
Element `ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.productOrServiceEnd` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.subDetail.patientPaid` (new:Money)
Element `ExplanationOfBenefit.addItem.detail.subDetail.patientPaid` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.patientPaid` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: `ExplanationOfBenefit.addItem.detail.subDetail.tax` (new:Money)
Element `ExplanationOfBenefit.addItem.detail.subDetail.tax` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.tax` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
R5: Additem subdetail level adjudication results (new)
R5: `ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome` (new:ExplanationOfBenefit.item.reviewOutcome)
Element `ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome` has a context of ExplanationOfBenefit.addItem.detail.subDetail based on following the parent source element upwards and mapping to `ExplanationOfBenefit`. Element `ExplanationOfBenefit.addItem.detail.subDetail.reviewOutcome` has no mapping targets in FHIR R4. Typically, this is because the element has been added (is a new element).
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.
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.
A note that describes or explains adjudication results in a human readable form.
Provides the insurer specific textual explanations associated with the processing.
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.
R5: `ExplanationOfBenefit.processNote.type` additional types (CodeableConcept) additional types from child elements (coding)
Element `ExplanationOfBenefit.processNote.type` is mapped to FHIR R4 element `ExplanationOfBenefit.processNote.type` as `SourceIsBroaderThanTarget`. The mappings for `ExplanationOfBenefit.processNote.type` do not cover the following types: CodeableConcept. The mappings for `ExplanationOfBenefit.processNote.type` do not cover the following types based on type expansion: coding.
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.
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.
Unit covered/serviced - individual or family.
The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual visits'.
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.