NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit ΣDomainResourceExplanation of Benefit resource
... identifier Σ0..*IdentifierBusiness Identifier
... claim[x] Σ0..1Claim reference
.... claimIdentifierIdentifier
.... claimReferenceReference(Claim)
... claimResponse[x] Σ0..1Claim response reference
.... claimResponseIdentifierIdentifier
.... claimResponseReferenceReference(ClaimResponse)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... disposition Σ0..1stringDisposition Message
... provider[x] Σ0..1Responsible provider for the claim
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization for the claim
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... precedence Σ0..1positiveIntPrecedence (primary, secondary, etc.)
... coverage Σ1..1BackboneElementInsurance or medical plan
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..*Reference(Device)Unique Device Identifier
..... adjudication Σ0..*BackboneElementDetail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..*Reference(Device)Unique Device Identifier
...... adjudication Σ0..*BackboneElementSubDetail adjudication
....... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monitory value
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monitory value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... category Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... reason Σ0..1CodingAdjudication reason
Adjudication Reason Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monitory value
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductable
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanitory text
... benefitBalance Σ0..*BackboneElementBalance by Benefit Category
.... category Σ1..1CodingBenefit Category
Benefit Category Codes (Example)
.... subCategory Σ0..1CodingBenefit SubCategory
Benefit SubCategory Codes (Example)
.... network Σ0..1CodingIn or out of network
Network Type Codes (Example)
.... unit Σ0..1CodingIndividual or family
Unit Type Codes (Example)
.... term Σ0..1CodingAnnual or lifetime
Benefit Term Codes (Example)
.... financial Σ0..*BackboneElementBenefit Summary
..... type Σ1..1CodingDeductable, visits, benefit amount
Benefit Type Codes (Example)
..... benefit[x] Σ0..1Benefits allowed
...... benefitUnsignedIntunsignedInt
...... benefitQuantityMoney
..... benefitUsed[x] Σ0..1Benefits used
...... benefitUsedUnsignedIntunsignedInt
...... benefitUsedQuantityMoney

doco Documentation for this format