This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). The current version which supercedes this version is 4.0.1. For a full list of available versions, see the Directory of published versions 
Generated Questionnaire for ExplanationOfBenefit
{
"resourceType": "Questionnaire",
"id": "qs1",
"contained": [
{
"resourceType": "ValueSet",
"id": "vs2",
"name": "Type options for ExplanationOfBenefit.author[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.author[x]",
"expansion": {
"identifier": "urn:uuid:c327c500-82a3-41d7-aea1-58ab67101007",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Organization",
"display": "Organization"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs3",
"name": "Type options for ExplanationOfBenefit.claim[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.claim[x]",
"expansion": {
"identifier": "urn:uuid:f92a90db-b94d-45cd-befd-544864383357",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Claim",
"display": "Claim"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs4",
"name": "Type options for ExplanationOfBenefit.claimResponse[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.claimResponse[x]",
"expansion": {
"identifier": "urn:uuid:1539e565-56e2-40f5-b463-c8c7f9fa96a3",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "ClaimResponse",
"display": "ClaimResponse"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs5",
"name": "Type options for ExplanationOfBenefit.provider[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.provider[x]",
"expansion": {
"identifier": "urn:uuid:317b3a09-9e10-440e-8c78-a54d272294b3",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Practitioner",
"display": "Practitioner"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs6",
"name": "Type options for ExplanationOfBenefit.organization[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.organization[x]",
"expansion": {
"identifier": "urn:uuid:a1803b00-98b0-43e1-b56b-abff579390dd",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Organization",
"display": "Organization"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs7",
"name": "Type options for ExplanationOfBenefit.facility[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.facility[x]",
"expansion": {
"identifier": "urn:uuid:31225e70-0c03-4fb7-b23d-bba49a0c2231",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Location",
"display": "Location"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs8",
"name": "Type options for ExplanationOfBenefit.related.claim[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.related.claim[x]",
"expansion": {
"identifier": "urn:uuid:9def752e-c503-4527-a87a-b1edd19b81bf",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Claim",
"display": "Claim"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs9",
"name": "Type options for ExplanationOfBenefit.prescription[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.prescription[x]",
"expansion": {
"identifier": "urn:uuid:9474bc70-b10b-493a-a881-25723c26f3c2",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "MedicationOrder",
"display": "MedicationOrder"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "VisionPrescription",
"display": "VisionPrescription"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs10",
"name": "Type options for ExplanationOfBenefit.originalPrescription[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.originalPrescription[x]",
"expansion": {
"identifier": "urn:uuid:2553fcfe-d926-4dac-a202-588b11fe2948",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "MedicationOrder",
"display": "MedicationOrder"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs11",
"name": "Type options for ExplanationOfBenefit.payee.party[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.payee.party[x]",
"expansion": {
"identifier": "urn:uuid:58b734e1-dcdb-4635-bf33-8d5c785d905e",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Practitioner",
"display": "Practitioner"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Organization",
"display": "Organization"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Patient",
"display": "Patient"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "RelatedPerson",
"display": "RelatedPerson"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs12",
"name": "Type options for ExplanationOfBenefit.referral[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.referral[x]",
"expansion": {
"identifier": "urn:uuid:3d91bf7e-e57c-44cd-a26c-ce2ea5d64d78",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "ReferralRequest",
"display": "ReferralRequest"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs13",
"name": "Type options for ExplanationOfBenefit.information.timing[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.information.timing[x]",
"expansion": {
"identifier": "urn:uuid:9898364e-758d-4c35-bf76-afe6da4f80d7",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "date",
"display": "date"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Period",
"display": "Period"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs14",
"name": "Type options for ExplanationOfBenefit.information.value[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.information.value[x]",
"expansion": {
"identifier": "urn:uuid:8a838ac1-055a-46d3-8a03-5b8dc41e77ea",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "string",
"display": "string"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Quantity",
"display": "Quantity"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs15",
"name": "Type options for ExplanationOfBenefit.procedure.procedure[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.procedure.procedure[x]",
"expansion": {
"identifier": "urn:uuid:c8fbff96-06ce-4960-9dfb-e89afddb1872",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Coding",
"display": "Coding"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Procedure",
"display": "Procedure"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs16",
"name": "Type options for ExplanationOfBenefit.patient[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.patient[x]",
"expansion": {
"identifier": "urn:uuid:e91d8345-07ea-4fc6-955b-3e6c506eba52",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Patient",
"display": "Patient"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs17",
"name": "Type options for ExplanationOfBenefit.coverage.coverage[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.coverage.coverage[x]",
"expansion": {
"identifier": "urn:uuid:9ae5e1e3-925b-4136-a750-7300c02e57a8",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Coverage",
"display": "Coverage"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs18",
"name": "Type options for ExplanationOfBenefit.accident.location[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.accident.location[x]",
"expansion": {
"identifier": "urn:uuid:de28eb6a-d8ff-4cff-887d-9758119721fa",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Address",
"display": "Address"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Location",
"display": "Location"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs19",
"name": "Type options for ExplanationOfBenefit.item.careTeam.provider[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.item.careTeam.provider[x]",
"expansion": {
"identifier": "urn:uuid:137bf257-b10e-4f2b-89f2-fe51b020622d",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Identifier",
"display": "Identifier"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Practitioner",
"display": "Practitioner"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Organization",
"display": "Organization"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs20",
"name": "Type options for ExplanationOfBenefit.item.serviced[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.item.serviced[x]",
"expansion": {
"identifier": "urn:uuid:dabf8811-9762-4f07-b86b-0d40658c3178",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "date",
"display": "date"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Period",
"display": "Period"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs21",
"name": "Type options for ExplanationOfBenefit.item.location[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.item.location[x]",
"expansion": {
"identifier": "urn:uuid:a7a4fe54-710e-47c7-850a-f8376dd52da6",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "Coding",
"display": "Coding"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Address",
"display": "Address"
},
{
"system": "http://hl7.org/fhir/resource-types",
"code": "Location",
"display": "Location"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs22",
"name": "Type options for ExplanationOfBenefit.benefitBalance.financial.benefit[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.benefitBalance.financial.benefit[x]",
"expansion": {
"identifier": "urn:uuid:8ca88180-2b1f-41ca-9fca-b1dead694465",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "unsignedInt",
"display": "unsignedInt"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "string",
"display": "string"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Money",
"display": "Money"
}
]
}
},
{
"resourceType": "ValueSet",
"id": "vs23",
"name": "Type options for ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]",
"status": "active",
"description": "Type options for ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]",
"expansion": {
"identifier": "urn:uuid:e669f7ee-ada6-443b-b205-8516c5d5df02",
"timestamp": "2016-08-11T17:06:40+10:00",
"contains": [
{
"system": "http://hl7.org/fhir/data-types",
"code": "unsignedInt",
"display": "unsignedInt"
},
{
"system": "http://hl7.org/fhir/data-types",
"code": "Money",
"display": "Money"
}
]
}
}
],
"identifier": [
{
"system": "urn:ietf:rfc:3986"
}
],
"status": "draft",
"date": "2016-08-11T17:02:54+10:00",
"publisher": "Health Level Seven International (Financial Management)",
"item": [
{
"linkId": "ExplanationOfBenefit",
"text": "Explanation of Benefit resource",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.id.value",
"text": "Logical id of this artifact",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.meta",
"text": "Metadata about the resource",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "uri"
}
],
"linkId": "ExplanationOfBenefit.implicitRules",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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 as much as possible.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.implicitRules.value",
"text": "A set of rules under which this content was created",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
}
],
"linkId": "ExplanationOfBenefit.language",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.language.value",
"text": "language",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.text",
"text": "Text summary of the resource, for human interpretation",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.contained",
"text": "Contained, inline Resources",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "May be used to represent additional information that is not part of the basic definition of the resource. 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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.identifier",
"text": "Business Identifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The EOB Business Identifier.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "code"
}
],
"linkId": "ExplanationOfBenefit.status",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The status of the resource instance.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.status.value",
"text": "status",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.author[x]",
"text": "Insurer",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The insurer which is responsible for the explanation of benefit.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.author[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs2"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.author[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.author[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.author[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.author[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.author[x]._Organization",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Organization"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.author[x]._Organization.value",
"text": "Organization",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.claim[x]",
"text": "Claim reference",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.claim[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs3"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.claim[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.claim[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.claim[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.claim[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.claim[x]._Claim",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Claim"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.claim[x]._Claim.value",
"text": "Claim",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.claimResponse[x]",
"text": "Claim response reference",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.claimResponse[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs4"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.claimResponse[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.claimResponse[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.claimResponse[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.claimResponse[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.claimResponse[x]._ClaimResponse",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "ClaimResponse"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.claimResponse[x]._ClaimResponse.value",
"text": "ClaimResponse",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.type",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional. Affects which fields and value sets are used.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.type.value",
"text": "Type or discipline",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.subType",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.subType.value",
"text": "Finer grained claim type information",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.ruleset",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The version of the specification on which this instance relies.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.ruleset.value",
"text": "Current specification followed",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.originalRuleset",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The version of the specification from which the original instance was created.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.originalRuleset.value",
"text": "Original specification followed",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.created",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The date when the EOB was created.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.created.value",
"text": "Creation date",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
}
],
"linkId": "ExplanationOfBenefit.billablePeriod",
"text": "Period for charge submission",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The billable period for which charges are being submitted.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.billablePeriod.low",
"text": "start:",
"type": "dateTime",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.billablePeriod.end",
"text": "end:",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.outcome",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Processing outcome errror, partial or complete processing.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.outcome.value",
"text": "complete | error | partial",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.disposition",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A description of the status of the adjudication. Do we need a disposition code?",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.disposition.value",
"text": "Disposition Message",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.provider[x]",
"text": "Responsible provider for the claim",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The provider which is responsible for the claim.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.provider[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs5"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.provider[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.provider[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.provider[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.provider[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.provider[x]._Practitioner",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Practitioner"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.provider[x]._Practitioner.value",
"text": "Practitioner",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.organization[x]",
"text": "Responsible organization for the claim",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The provider which is responsible for the claim.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.organization[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs6"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.organization[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.organization[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.organization[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.organization[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.organization[x]._Organization",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Organization"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.organization[x]._Organization.value",
"text": "Organization",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.facility[x]",
"text": "Servicing Facility",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Facility where the services were provided.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.facility[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs7"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.facility[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.facility[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.facility[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.facility[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.facility[x]._Location",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Location"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.facility[x]._Location.value",
"text": "Location",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.related",
"text": "Related Claims which may be revelant to processing this claimn",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Other claims which are related to this claim such as prior claim versions or for related services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.related.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.related.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.related.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.related.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.related.claim[x]",
"text": "Reference to the related claim",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Other claims which are related to this claim such as prior claim versions or for related services. Do we need a relationship code?",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.related.claim[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs8"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.related.claim[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.related.claim[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.related.claim[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.related.claim[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.related.claim[x]._Claim",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Claim"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.related.claim[x]._Claim.value",
"text": "Claim",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.related.relationship",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "For example prior or umbrella.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.related.relationship.value",
"text": "How the reference claim is related",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.related.reference",
"text": "Related file or case reference",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.related.reference.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.related.reference.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.related.reference.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.prescription[x]",
"text": "Prescription",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Prescription to support the dispensing of Pharmacy or Vision products.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.prescription[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs9"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.prescription[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.prescription[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.prescription[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.prescription[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.prescription[x]._MedicationOrder",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "MedicationOrder"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.prescription[x]._MedicationOrder.value",
"text": "MedicationOrder",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.prescription[x]._VisionPrescription",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "VisionPrescription"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.prescription[x]._VisionPrescription.value",
"text": "VisionPrescription",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.originalPrescription[x]",
"text": "Original Prescription",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.originalPrescription[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs10"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.originalPrescription[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.originalPrescription[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.originalPrescription[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.originalPrescription[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.originalPrescription[x]._MedicationOrder",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "MedicationOrder"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.originalPrescription[x]._MedicationOrder.value",
"text": "MedicationOrder",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.payee",
"text": "Payee",
"type": "group",
"required": false,
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The party to be reimbursed for the services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.payee.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payee.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.payee.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.payee.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.payee.type",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Type of Party to be reimbursed: Subscriber, provider, other.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payee.type.value",
"text": "Type of party: Subscriber, Provider, other",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.payee.resourceType",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "organization | patient | practitioner | relatedperson.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payee.resourceType.value",
"text": "organization | patient | practitioner | relatedperson",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]",
"text": "Party to receive the payable",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Party to be reimbursed: Subscriber, provider, other.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payee.party[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs11"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.payee.party[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payee.party[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payee.party[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Practitioner",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Practitioner"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Practitioner.value",
"text": "Practitioner",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Organization",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Organization"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Organization.value",
"text": "Organization",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Patient",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Patient"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._Patient.value",
"text": "Patient",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._RelatedPerson",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "RelatedPerson"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.payee.party[x]._RelatedPerson.value",
"text": "RelatedPerson",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.referral[x]",
"text": "Treatment Referral",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.referral[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs12"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.referral[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.referral[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.referral[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.referral[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.referral[x]._ReferralRequest",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "ReferralRequest"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.referral[x]._ReferralRequest.value",
"text": "ReferralRequest",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.information",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.information.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.information.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.information.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.information.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.information.category",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The general class of the information supplied: information; exception; accident, employment; onset, etc. This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.information.category.value",
"text": "Category of information",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.information.code",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. This may contain the local bill type codes such as the US UB-04 bill type code.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.information.code.value",
"text": "Type of information",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.information.timing[x]",
"text": "When it occurred",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The date when or period to which this information refers.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.information.timing[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs13"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.information.timing[x]._date",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.information.timing[x]._date.value",
"text": "date",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
}
],
"linkId": "ExplanationOfBenefit.information.timing[x]._Period",
"text": "Period",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.information.timing[x]._Period.low",
"text": "start:",
"type": "dateTime",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.information.timing[x]._Period.end",
"text": "end:",
"type": "dateTime",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.information.value[x]",
"text": "Additional Data",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Additional data.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.information.value[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs14"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.information.value[x]._string",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.information.value[x]._string.value",
"text": "string",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity",
"text": "Quantity",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.information.value[x]._Quantity.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.diagnosis",
"text": "Diagnosis",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Ordered list of patient diagnosis for which care is sought.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.diagnosis.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.diagnosis.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.diagnosis.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.diagnosis.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.diagnosis.sequence",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Sequence of diagnosis which serves to order and provide a link.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.diagnosis.sequence.value",
"text": "Number to covey order of diagnosis",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The diagnosis.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.diagnosis.diagnosis.value",
"text": "Patient's list of diagnosis",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.diagnosis.type",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of the Diagnosis, for example: admitting,. Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.diagnosis.type.value",
"text": "Type of Diagnosis",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.diagnosis.drg",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The Diagnosis Related Group (DRG) code based on the assigned grouping code system.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.diagnosis.drg.value",
"text": "Diagnosis Related Group",
"type": "open-choice",
"required": false,
"repeats": false
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.procedure",
"text": "Procedures performed",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Ordered list of patient procedures performed to support the adjudication.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.procedure.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.procedure.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.procedure.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.procedure.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.procedure.sequence",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Sequence of procedures which serves to order and provide a link.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.procedure.sequence.value",
"text": "Procedure sequence for reference",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.procedure.date",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Date and optionally time the procedure was performed . SB DateTime??",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.procedure.date.value",
"text": "When the procedure was performed",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.procedure.procedure[x]",
"text": "Patient's list of procedures performed",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The procedure code.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs15"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._Coding",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._Coding.value",
"text": "Coding",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._Procedure",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Procedure"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.procedure.procedure[x]._Procedure.value",
"text": "Procedure",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.patient[x]",
"text": "The subject of the Products and Services",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Patient Resource.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.patient[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs16"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.patient[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.patient[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.patient[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.patient[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.patient[x]._Patient",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Patient"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.patient[x]._Patient.value",
"text": "Patient",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.precedence",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Precedence (primary, secondary, etc.).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.precedence.value",
"text": "Precedence (primary, secondary, etc.)",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.coverage",
"text": "Insurance or medical plan",
"type": "group",
"required": true,
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Financial instrument by which payment information for health care.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.coverage.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.coverage.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.coverage.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.coverage.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.coverage.coverage[x]",
"text": "Insurance information",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Reference to the program or plan identification, underwriter or payor.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs17"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Coverage",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Coverage"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.coverage.coverage[x]._Coverage.value",
"text": "Coverage",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.coverage.preAuthRef",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of references from the Insurer to which these services pertain.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.coverage.preAuthRef.value",
"text": "Pre-Authorization/Determination Reference",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.accident",
"type": "group",
"required": false,
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An accident which resulted in the need for healthcare services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.accident.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.accident.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.accident.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.accident.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.accident.date",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Date of an accident which these services are addressing.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.accident.date.value",
"text": "When the accident occurred",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.accident.type",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Type of accident: work, auto, etc.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.accident.type.value",
"text": "The nature of the accident",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.accident.location[x]",
"text": "Accident Place",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Where the accident occurred.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs18"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Address"
}
],
"linkId": "ExplanationOfBenefit.accident.location[x]._Address",
"text": "Address",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.text",
"text": "text:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.line",
"text": "line:",
"type": "string",
"required": false,
"repeats": true
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.city",
"text": "city:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.state",
"text": "state:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.postalCode",
"text": "post code:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.country",
"text": "country:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.accident.location[x]._Address.use",
"text": "use:",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.accident.location[x]._Location",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Location"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.accident.location[x]._Location.value",
"text": "Location",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
}
],
"linkId": "ExplanationOfBenefit.employmentImpacted",
"text": "Period unable to work",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.employmentImpacted.low",
"text": "start:",
"type": "dateTime",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.employmentImpacted.end",
"text": "end:",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
}
],
"linkId": "ExplanationOfBenefit.hospitalization",
"text": "Period in hospital",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The start and optional end dates of when the patient was confined to a treatment center.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.hospitalization.low",
"text": "start:",
"type": "dateTime",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.hospitalization.end",
"text": "end:",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item",
"text": "Goods and Services",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "First tier of goods and services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.sequence",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A service line number.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.sequence.value",
"text": "Service instance",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.careTeam",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The members of the team who provided the overall service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs19"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Identifier",
"text": "Identifier",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Practitioner",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Practitioner"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Practitioner.value",
"text": "Practitioner",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Organization",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Organization"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.provider[x]._Organization.value",
"text": "Organization",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.responsible",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The practitioner who is billing and responsible for the claimed services rendered to the patient.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.responsible.value",
"text": "Billing practitioner",
"type": "boolean",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.role",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.role.value",
"text": "Role on the team",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.careTeam.qualification",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The qualification which is applicable for this service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.careTeam.qualification.value",
"text": "Type, classification or Specialization",
"type": "open-choice",
"required": false,
"repeats": false
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.diagnosisLinkId",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Diagnosis applicable for this service or product line.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.diagnosisLinkId.value",
"text": "Applicable diagnoses",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.revenue",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of reveneu or cost center providing the product and/or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.revenue.value",
"text": "Revenue or cost center code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Health Care Service Type Codes to identify the classification of service or benefits.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.category.value",
"text": "Type of service or product",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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'.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.service.value",
"text": "Billing Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.modifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.modifier.value",
"text": "Service/Product billing modifiers",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.programCode",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.programCode.value",
"text": "Program specific reason for item inclusion",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.item.serviced[x]",
"text": "Date or dates of Service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The date or dates when the enclosed suite of services were performed or completed.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.serviced[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs20"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.item.serviced[x]._date",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.item.serviced[x]._date.value",
"text": "date",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Period"
}
],
"linkId": "ExplanationOfBenefit.item.serviced[x]._Period",
"text": "Period",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.item.serviced[x]._Period.low",
"text": "start:",
"type": "dateTime",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.serviced[x]._Period.end",
"text": "end:",
"type": "dateTime",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.item.location[x]",
"text": "Place of service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Where the service was provided.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs21"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.location[x]._Coding",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.item.location[x]._Coding.value",
"text": "Coding",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Address"
}
],
"linkId": "ExplanationOfBenefit.item.location[x]._Address",
"text": "Address",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.text",
"text": "text:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.line",
"text": "line:",
"type": "string",
"required": false,
"repeats": true
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.city",
"text": "city:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.state",
"text": "state:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.postalCode",
"text": "post code:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.country",
"text": "country:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.location[x]._Address.use",
"text": "use:",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.location[x]._Location",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Location"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.location[x]._Location.value",
"text": "Location",
"type": "reference",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.quantity",
"text": "Count of Products or Services",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The number of repetitions of a service or product.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.quantity.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.quantity.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.quantity.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.quantity.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.quantity.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.unitPrice",
"text": "Fee, charge or cost per point",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.unitPrice.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.unitPrice.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.unitPrice.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.unitPrice.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.unitPrice.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.factor",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.factor.value",
"text": "Price scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.points",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.points.value",
"text": "Difficulty scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.net",
"text": "Total item cost",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.net.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.net.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.net.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.net.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.net.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.udi",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "List of Unique Device Identifiers associated with this line item.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Device"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.udi.value",
"text": "Unique Device Identifier",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.bodySite",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Physical service site on the patient (limb, tooth, etc).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.bodySite.value",
"text": "Service Location",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.subSite",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A region or surface of the site, eg. limb region or tooth surface(s).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.subSite.value",
"text": "Service Sub-location",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.noteNumber",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of note references to the notes provided below.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.noteNumber.value",
"text": "List of note numbers which apply",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.adjudication",
"text": "Adjudication details",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The adjudications results.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.adjudication.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.adjudication.category",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Code indicating: Co-Pay, deductable, elegible, benefit, tax, etc.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.category.value",
"text": "Adjudication category such as co-pay, eligible, benefit, etc.",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.adjudication.reason",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Adjudication reason such as limit reached.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.reason.value",
"text": "Adjudication reason",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.adjudication.amount",
"text": "Monetary amount",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Monitory amount associated with the code.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.amount.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.amount.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.amount.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.amount.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.amount.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.adjudication.value",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.adjudication.value.value",
"text": "Non-monitory value",
"type": "decimal",
"required": false,
"repeats": false
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail",
"text": "Additional items",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Second tier of goods and services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.detail.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.detail.sequence",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A service line number.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.sequence.value",
"text": "Service instance",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.type",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of product or service. ItemType.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.type.value",
"text": "Group or type of product or service",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.revenue",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of reveneu or cost center providing the product and/or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.revenue.value",
"text": "Revenue or cost center code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Health Care Service Type Codes to identify the classification of service or benefits.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.category.value",
"text": "Type of service or product",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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'.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.service.value",
"text": "Billing Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.modifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.modifier.value",
"text": "Service/Product billing modifiers",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.programCode",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.programCode.value",
"text": "Program specific reason for item inclusion",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.quantity",
"text": "Count of Products or Services",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The number of repetitions of a service or product.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.quantity.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.quantity.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.quantity.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.quantity.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.quantity.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.unitPrice",
"text": "Fee, charge or cost per point",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.unitPrice.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.detail.factor",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.factor.value",
"text": "Price scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.detail.points",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.points.value",
"text": "Difficulty scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.net",
"text": "Total additional item cost",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.net.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.net.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.net.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.net.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.net.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.detail.udi",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "List of Unique Device Identifiers associated with this line item.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Device"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.detail.udi.value",
"text": "Unique Device Identifier",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.detail.noteNumber",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of note references to the notes provided below.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.noteNumber.value",
"text": "List of note numbers which apply",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.adjudication",
"text": "Detail adjudication",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The adjudications results.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail",
"text": "Additional items",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Third tier of goods and services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.sequence",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A service line number.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.sequence.value",
"text": "Service instance",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.type",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of product or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.type.value",
"text": "Type of product or service",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of reveneu or cost center providing the product and/or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.revenue.value",
"text": "Revenue or cost center code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Health Care Service Type Codes to identify the classification of service or benefits.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.category.value",
"text": "Type of service or product",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.service.value",
"text": "Billing Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.modifier.value",
"text": "Service/Product billing modifiers",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.programCode.value",
"text": "Program specific reason for item inclusion",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity",
"text": "Count of Products or Services",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The number of repetitions of a service or product.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.quantity.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice",
"text": "Fee, charge or cost per point",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The fee for an addittional service or product or charge.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.unitPrice.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.factor",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.factor.value",
"text": "Price scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "decimal"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.points",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.points.value",
"text": "Difficulty scaling factor",
"type": "decimal",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net",
"text": "Net additional item cost",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.net.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Reference"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.udi",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "List of Unique Device Identifiers associated with this line item.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-allowedResource",
"valueCode": "Device"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "subject=$subj&patient=$subj&encounter=$encounter"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.udi.value",
"text": "Unique Device Identifier",
"type": "reference",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.item.detail.subDetail.noteNumber",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of note references to the notes provided below.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.noteNumber.value",
"text": "List of note numbers which apply",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.detail.subDetail.adjudication",
"text": "SubDetail adjudication",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The adjudications results.",
"type": "display"
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.item.prosthesis",
"text": "Prosthetic details",
"type": "group",
"required": false,
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The materials and placement date of prior fixed prosthesis.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.item.prosthesis.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "boolean"
}
],
"linkId": "ExplanationOfBenefit.item.prosthesis.initial",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Indicates whether this is the initial placement of a fixed prosthesis.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.initial.value",
"text": "Is this the initial service",
"type": "boolean",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.item.prosthesis.priorDate",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Date of the initial placement.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.priorDate.value",
"text": "Initial service Date",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.item.prosthesis.priorMaterial",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Material of the prior denture or bridge prosthesis (Oral).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.item.prosthesis.priorMaterial.value",
"text": "Prosthetic Material",
"type": "open-choice",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem",
"text": "Insurer added line items",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The first tier service adjudications for payor added services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.addItem.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.addItem.sequenceLinkId",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "List of input service items which this service line is intended to replace.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.sequenceLinkId.value",
"text": "Service instances",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.revenue",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of reveneu or cost center providing the product and/or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.revenue.value",
"text": "Revenue or cost center code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Health Care Service Type Codes to identify the classification of service or benefits.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.category.value",
"text": "Type of service or product",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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'.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.service.value",
"text": "Billing Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.modifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.modifier.value",
"text": "Service/Product billing modifiers",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.addItem.fee",
"text": "Professional fee or Product charge",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The fee charged for the professional service or product.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.fee.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.fee.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.fee.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.fee.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.fee.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.addItem.noteNumber",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of note references to the notes provided below.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.noteNumber.value",
"text": "List of note numbers which apply",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.adjudication",
"text": "Added items adjudication",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The adjudications results.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.detail",
"text": "Added items details",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The second tier service adjudications for payor added services.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.revenue",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The type of reveneu or cost center providing the product and/or service.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.revenue.value",
"text": "Revenue or cost center code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Health Care Service Type Codes to identify the classification of service or benefits.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.category.value",
"text": "Type of service or product",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.service",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.service.value",
"text": "Billing Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.modifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.modifier.value",
"text": "Service/Product billing modifiers",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.fee",
"text": "Professional fee or Product charge",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The fee charged for the professional service or product.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.fee.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.fee.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.fee.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.fee.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.fee.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.addItem.detail.noteNumber",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of note references to the notes provided below.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.noteNumber.value",
"text": "List of note numbers which apply",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.addItem.detail.adjudication",
"text": "Added items detail adjudication",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The adjudications results.",
"type": "display"
}
]
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.missingTeeth",
"text": "Only if type = oral",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.missingTeeth.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.missingTeeth.tooth",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The code identifying which tooth is missing.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.tooth.value",
"text": "Tooth Code",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.missingTeeth.reason",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Missing reason may be: E-extraction, O-other.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.reason.value",
"text": "Reason for missing",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.missingTeeth.extractionDate",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The date of the extraction either known from records or patient reported estimate.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.missingTeeth.extractionDate.value",
"text": "Date of Extraction",
"type": "dateTime",
"required": false,
"repeats": false
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.totalCost",
"text": "Total Cost of service from the Claim",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The total cost of the services reported.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.totalCost.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalCost.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalCost.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalCost.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalCost.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.unallocDeductable",
"text": "Unallocated deductable",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The amount of deductable applied which was not allocated to any particular service line.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.unallocDeductable.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.unallocDeductable.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.unallocDeductable.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.unallocDeductable.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.unallocDeductable.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.totalBenefit",
"text": "Total benefit payable for the Claim",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable).",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.totalBenefit.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalBenefit.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalBenefit.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalBenefit.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.totalBenefit.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.payment",
"type": "group",
"required": false,
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Payment details for the claim if the claim has been paid.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.payment.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.payment.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.payment.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.payment.type",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Whether this represents partial or complete payment of the claim.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.type.value",
"text": "Partial or Complete",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.payment.adjustment",
"text": "Payment adjustment for non-Claim issues",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.adjustment.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.adjustment.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.adjustment.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.adjustment.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.adjustment.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.payment.adjustmentReason",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Reason for the payment adjustment.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.adjustmentReason.value",
"text": "Reason for Payment adjustment",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "datetime"
}
],
"linkId": "ExplanationOfBenefit.payment.date",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Estimated payment date.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.date.value",
"text": "Expected date of Payment",
"type": "dateTime",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.payment.amount",
"text": "Payment amount",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Payable less any payment adjustment.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.amount.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.amount.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.amount.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.amount.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.amount.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Identifier"
}
],
"linkId": "ExplanationOfBenefit.payment.identifier",
"text": "Payment identifier",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Payment identifer.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.payment.identifier.label",
"text": "label:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.identifier.system",
"text": "system:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.payment.identifier.value",
"text": "value:",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.form",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The form to be used for printing the content.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.form.value",
"text": "Printed Form Identifier",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.note",
"text": "Processing notes",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Note text.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.note.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.note.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.note.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.note.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.note.number",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "An integer associated with each note which may be referred to from each service line item.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.note.number.value",
"text": "Note Number for this note",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.note.type",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The note purpose: Print/Display.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.note.type.value",
"text": "display | print | printoper",
"type": "choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.note.text",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The note text.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.note.text.value",
"text": "Note explanitory text",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.note.language",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.note.language.value",
"text": "Language",
"type": "open-choice",
"required": false,
"repeats": false
}
]
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance",
"text": "Balance by Benefit Category",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Balance by Benefit Category.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.category",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Dental, Vision, Medical, Pharmacy, Rehab etc.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.category.value",
"text": "Benefit Category",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.subCategory",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Dental: basic, major, ortho; Vision exam, glasses, contacts; etc.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.subCategory.value",
"text": "Benefit SubCategory",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.name",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A short name or tag for the benefit, for example MED01, or DENT2.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.name.value",
"text": "Short name for the benefit",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.description",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "A richer description of the benefit, for example 'DENT2 covers 100% of basic, 50% of major but exclused Ortho, Implants and Costmetic services'.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.description.value",
"text": "Description of the benefit",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.network",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Network designation.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.network.value",
"text": "In or out of network",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.unit",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Unit designation: individual or family.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.unit.value",
"text": "Individual or family",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.term",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "The term or period of the values such as 'maximum lifetime benefit' or 'maximum annual vistis'.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.term.value",
"text": "Annual or lifetime",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial",
"text": "Benefit Summary",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Benefits Used to date.",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.id",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.id.value",
"text": "xml:id (or equivalent in JSON)",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.extension",
"text": "Additional Content defined by implementations",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.modifierExtension",
"text": "Extensions that cannot be ignored",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "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. 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.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Coding"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type",
"type": "group",
"required": true,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Deductable, visits, benefit amount.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.type.value",
"text": "Deductable, visits, benefit amount",
"type": "open-choice",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]",
"text": "Benefits allowed",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Benefits allowed.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs22"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._unsignedInt",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._unsignedInt.value",
"text": "unsignedInt",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "string"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._string",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._string.value",
"text": "string",
"type": "string",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money",
"text": "Money",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefit[x]._Money.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs",
"valueInteger": 1
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]",
"text": "Benefits used",
"type": "group",
"required": false,
"repeats": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "flyover",
"display": "Fly-over"
}
]
}
}
],
"text": "Benefits used.",
"type": "display"
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._type",
"text": "type",
"type": "choice",
"required": false,
"repeats": false,
"options": {
"reference": "#vs23"
},
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "integer"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._unsignedInt",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._unsignedInt.value",
"text": "unsignedInt",
"type": "integer",
"required": false,
"repeats": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-fhirType",
"valueString": "Quantity"
}
],
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money",
"text": "Money",
"type": "group",
"item": [
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money.comparator",
"text": "comp:",
"type": "choice",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money.value",
"text": "value:",
"type": "decimal",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money.units",
"text": "units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money.code",
"text": "coded units:",
"type": "string",
"required": false,
"repeats": false
},
{
"linkId": "ExplanationOfBenefit.benefitBalance.financial.benefitUsed[x]._Money.system",
"text": "units system:",
"type": "string",
"required": false,
"repeats": false
}
]
}
]
}
]
}
]
}
]
}
]
}
]
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.