NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit ΣDomainResourceExplanation of Benefit resource
... identifier Σ0..*IdentifierBusiness Identifier
... claim Σ0..1Reference(Claim)Claim reference
... claimResponse Σ0..1Reference(ClaimResponse)Claim response reference
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... disposition Σ0..1stringDisposition Message
... provider Σ0..1Reference(Practitioner)Responsible provider for the claim
... organization Σ0..1Reference(Organization)Responsible organization for the claim
... facility Σ0..1Reference(Location)Servicing Facility
... relatedClaim Σ0..*Reference(Claim)Related Claims
... prescription Σ0..1Reference(MedicationOrder | VisionPrescription)Prescription
... originalPrescription Σ0..1Reference(MedicationOrder)Original Prescription
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
.... provider Σ0..1Reference(Practitioner)Provider who is the payee
.... organization Σ0..1Reference(Organization)Organization who is the payee
.... person Σ0..1Reference(Patient)Other person who is the payee
... referral Σ0..1Reference(ReferralRequest)Treatment Referral
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntSequence of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient Σ1..1Reference(Patient)The subject of the Products and Services
... precedence Σ0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage Σ1..1BackboneElementInsurance or medical plan
.... coverage Σ1..1Reference(Coverage)Insurance information
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
... exception Σ0..*CodingEligibility exceptions
Exception Codes (Example)
... school Σ0..1stringName of School
... accidentDate Σ0..1dateAccident Date
... accidentType Σ0..1CodingAccident Type
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationStringstring
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset[x] Σ0..1Illness, injury or treatable condition date
.... onsetDatedate
.... onsetPeriodPeriod
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider Σ0..1Reference(Practitioner)Responsible practitioner
.... diagnosisLinkId Σ0..*positiveIntDiagnosis Link
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite Σ0..1CodingService Location
Surface Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
..... adjudication Σ0..*BackboneElementDetail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
...... adjudication Σ0..*BackboneElementSubDetail adjudication
....... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monitory value
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
... claimTotal Σ0..1MoneyTotal claim cost
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction
... unallocDeductable Σ0..1MoneyUnallocated deductable
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanitory text
... benefitBalance Σ0..*BackboneElementBalance by Benefit Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney

doco Documentation for this format