This page is part of a downloaded copy of this specification. This page is part of the CARIN Blue Button Implementation Guide (v0.1.0: STU1 Ballot 1) based on FHIR R4. For a full list of available versions, see the Directory of published versions
EOB Inpatient Facility mapping
[Previous Page](undefined)Slice | L0 | L1 | L2 | L3 | L4 | Flag | Cardinality | DataType / Value Set |
Description | MapID | CARIN CPCDS Data Element Name | Cardinality / DataType |
Value Set Comments | Working Note | ||||||||
ExplanationOfBenefit | TU | DomainResource | Explanation of Benefit resource | |||||||||||||||||||
ExplanationOfBenefit | Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |||||||||||||||||||||
ExplanationOfBenefit | identifier | 1..* | Identifier | Business Identifier for the resource | 35 | Claim unique identifier | ||||||||||||||||
ExplanationOfBenefit | status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error | 140 | Claim processing status
code |
value = active | cancelled | entered-in-error | ||||||||||||||
ExplanationOfBenefit | status | ExplanationOfBenefitStatus (Required) | ||||||||||||||||||||
ExplanationOfBenefit | type | Σ | 1..1 | CodeableConcept | Category or discipline | 16 | Claim type | values: Inpatient Facility | ||||||||||||||
ExplanationOfBenefit | type | Claim Type Codes (Extensible) | 16 | Claim type | http://terminology.hl7.org/CodeSystem/claim-type | These define the Claims profiles (there is also a Coverage profile). | ||||||||||||||||
ExplanationOfBenefit | subtype | 0..1 | CodeableConcept | More granular claim type | 15 | [1..1] (CD-CHAR(14)) | values: Inpatient Facility - Acute | Inpatient Facility - Non-Acute | CPCDS: Removed from scope | ||||||||||||||
ExplanationOfBenefit | subtype | Example Claim SubType Codes (Example) | 15 | [1..1] (CD-CHAR(14)) | ||||||||||||||||||
ExplanationOfBenefit | use | Σ | 1..1 | code | claim | preauthorization | predetermination | New | value = claim | |||||||||||||||
ExplanationOfBenefit | use | Use (Required) | ||||||||||||||||||||
ExplanationOfBenefit | patient--> | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | Ref (1) | Member id | [1.1] (CHAR) | Contained | |||||||||||||
ExplanationOfBenefit | patient--> | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | Ref (109) | Patient account number | [1.1] (CHAR) | Contained | |||||||||||||
ExplanationOfBenefit | patient--> | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | Ref (110) | Medical record number | [1.1] (CHAR) | Contained | |||||||||||||
ExplanationOfBenefit | billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | 18, 19 | Member admission date, Member discharge date | [1..1] (TS8) | period.start period.end |
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ExplanationOfBenefit | created | Σ | 1..1 | dateTime | Response creation date | new | [1..1] (TS8) | [1] | ||||||||||||||
ExplanationOfBenefit | enterer--> | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | ||||||||||||||||||
ExplanationOfBenefit | insurer--> | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | Ref (2, 5) | Claim payer Identifier | Organization.identifier | Same as insurance.coverage.organization. Party responsible for reimbursing the provider. | |||||||||||||
ExplanationOfBenefit | provider--> | Σ | 1..1 | Reference(PractionerRole) | Party responsible for the claim | Ref (89) | [0..1] (CD-CHAR(5)) | Organization.address.zipcode | ||||||||||||||
ExplanationOfBenefit | provider--> | Σ | 1..1 | Reference(Organization) | Party responsible for the claim | Ref (94) | Claim billing provider NPI | [1..1] CHAR(10) | Organization.identifier | |||||||||||||
ExplanationOfBenefit | priority | 0..1 | CodeableConcept | Desired processing urgency | ||||||||||||||||||
ExplanationOfBenefit | priority | ProcessPriority (Example) | ||||||||||||||||||||
ExplanationOfBenefit | fundsReservedRequested | 0..1 | CodeableConcept | For whom to reserve funds | ||||||||||||||||||
ExplanationOfBenefit | fundsReservedRequested | FundsReserve (Example) | ||||||||||||||||||||
ExplanationOfBenefit | fundsReserve | 0..1 | CodeableConcept | Funds reserved status | ||||||||||||||||||
ExplanationOfBenefit | fundsReserve | FundsReserve (Example) | ||||||||||||||||||||
ExplanationOfBenefit | related | 0..* | BackboneElement | Prior or corollary claims | 111, 112 | Claim adjusted from
identifier Claim adjusted to identifier |
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ExplanationOfBenefit | related | claim--> | 0..1 | Reference(Claim) | Reference to the related claim | |||||||||||||||||
ExplanationOfBenefit | related | relationship | 0..1 | CodeableConcept | How the reference claim is related | New(111, 112) | ||||||||||||||||
ExplanationOfBenefit | related | relationship | Example Related Claim Relationship Codes (Example) | New(111, 112) | values set TBD prior | replaced by |
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ExplanationOfBenefit | related | reference | 0..1 | Identifier | File or case reference | 111, 112 | ||||||||||||||||
ExplanationOfBenefit | prescription--> | 0..1 | Reference(MedicationRequest| VisionPrescription) | Prescription authorizing services or products | ||||||||||||||||||
ExplanationOfBenefit | originalPrescription--> | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller | ||||||||||||||||||
ExplanationOfBenefit | payee | 0..1 | BackboneElement | Recipient of benefits payable | ||||||||||||||||||
ExplanationOfBenefit | payee | type | 0..1 | CodeableConcept | Category of recipient | 120 | Claim payee type code | |||||||||||||||
ExplanationOfBenefit | payee | type | PayeeType (Example) | 120 | Claim payee type code | subscriber | provider | other | ||||||||||||||||
ExplanationOfBenefit | payee | party--> | 0..1 | Reference(PractitionerRole | Patient) | Recipient reference | 121 | Claim payee | |||||||||||||||
ExplanationOfBenefit | referral--> | 0..1 | Reference(ServiceRequest) | Treatment Referral | ||||||||||||||||||
ExplanationOfBenefit | facility--> | 0..1 | Reference(Location) | Servicing Facility | ||||||||||||||||||
ExplanationOfBenefit | claim--> | 0..1 | Reference(Claim) | Claim reference | ||||||||||||||||||
ExplanationOfBenefit | claimResponse--> | 0..1 | Reference(ClaimResponse) | Claim response reference | ||||||||||||||||||
ExplanationOfBenefit | outcome | Σ | 1..1 | code | queued | complete | error | partial | New | value = complete | |||||||||||||||
ExplanationOfBenefit | outcome | Claim Processing Codes (Required) | New | |||||||||||||||||||
ExplanationOfBenefit | disposition | 0..1 | string | Disposition Message | ||||||||||||||||||
ExplanationOfBenefit | preAuthRef | 0..* | string | Preauthorization reference | ||||||||||||||||||
ExplanationOfBenefit | preAuthRefPeriod | 0..* | Period | Preauthorization in-effect period | ||||||||||||||||||
ExplanationOfBenefit | careTeam | 0..* | BackboneElement | Care Team members | ||||||||||||||||||
ExplanationOfBenefit | careTeam | sequence | 1..1 | positiveInt | Order of care team | |||||||||||||||||
ExplanationOfBenefit | careTeam | provider--> | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | Ref (93, 95, 96, 99) | Provider NPIs | [1..1] CHAR(10) | PractionerRole.practioner --> Practioner.identifier | PractionerRole.code = attending | performing | pcp | referring | ||||||||||||
ExplanationOfBenefit | careTeam | responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||||||||||||||
ExplanationOfBenefit | careTeam | role | 0..1 | CodeableConcept | Function within the team | |||||||||||||||||
ExplanationOfBenefit | careTeam | role | Claim Care Team Role Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | careTeam | qualification | 0..1 | CodeableConcept | Practitioner credential or specialization | |||||||||||||||||
ExplanationOfBenefit | careTeam | qualification | Example Provider Qualification Codes (Example) | |||||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 101 | reference supportinginfo.sequence rule | ||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 101 | value = 'billingnetworkcontractingstatus' | ||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 101 | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 101 | Claim billing provider network status | ||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 101 | Claim billing provider network status | values: contracted | non-contracted | |||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
billingnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 101 | reference supportinginfo.sequence rule | ||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 101 | value = 'attendingnetworkcontractingstatus' | ||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 101 | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 101 | Claim attending provider network status | ||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 101 | Claim attending provider network status | values: contracted | non-contracted | |||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
attendingnetworkcontractingstatu | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 101 | reference supportinginfo.sequence rule | ||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 101 | value = 'referringnetworkcontractingstatus' | ||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 101 | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 101 | Claim Referring Physican Network Status | ||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 101 | Claim Referring Physican Network Status | values: contracted | non-contracted | |||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
referringnetworkcontractingstatus | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 88 | reference supportinginfo.sequence rule | ||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 88 | value = 'clmrecvddate' | ||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | ||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | ||||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | 88 | Claim received date | [1..1] (TS8) | ||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 34 | reference supportinginfo.sequence rule | ||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 34 | value = 'typeofservice' | ||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 34 | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 34 | Type of service | [1.1] (CD-CHAR(5)) | coding.system = url of code
system coding.code = the code value |
https://www.resdac.org/sites/resdac.umn.edu/files/CMS%20Type%20of%20Service%20Table.txt | |||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 34 | Type of service | [1.1] (CD-CHAR(5)) | |||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
typeofservice | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | 17 | ||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 17 | reference supportinginfo.sequence rule | ||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 17 | value = 'Type of Bill' | ||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 17 | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 17 | [1..1] (CD-CHAR(3)) UB-04 | coding.system = url of code
system coding.code = the code value |
Not applicable for CARIN | ||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 17 | [1..1] (CD-CHAR(3)) UB-04 | Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill. | Not applicable for CARIN | ||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
TypeofBill | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | 114 | ||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 114 | reference supportinginfo.sequence rule | ||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 114 | value = 'tob-typeoffacility' | ||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 114 | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 114 | Claim bill facility type code | [1..1] (CD-CHAR(1)) UB-04 | coding.system = url of code
system coding.code = the code value |
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tob-typeoffacility | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 114 | Claim bill facility type code | [1..1] (CD-CHAR(1)) UB-04 | Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill. | ||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
tob-typeoffacility | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | 115 | ||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 115 | reference supportinginfo.sequence rule | ||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 115 | value = 'tob-billclassification' | ||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 115 | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 115 | Claim service classification type code | [1..1] (CD-CHAR(1)) UB-04 | coding.system = url of code
system coding.code = the code value |
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tob-billclassification | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 115 | Claim service classification type code | [1..1] (CD-CHAR(1)) UB-04 | Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill. | ||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
tob-billclassification | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | 116 | ||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 116 | reference supportinginfo.sequence rule | ||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 116 | value = 'tob-frequency' | ||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 116 | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 116 | Claim frequency code | [1..1] (CD-CHAR(1)) UB-04 | coding.system = url of code
system coding.code = the code value |
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tob-frequency | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 116 | Claim frequency code | [1..1] (CD-CHAR(1)) UB-04 | Note: Use the code set from UB-04 Form Locator (FL 4) Type Bill. | ||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
tob-frequency | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 13 | reference supportinginfo.sequence rule | ||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 13 | value = 'admsrc' | ||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 13 | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 13 | Claim source inpatient admission code | [1..1] (CD-CHAR(2))UB-04 | coding.system = url of code
system coding.code = the code value |
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admsrc | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 13 | Claim source inpatient admission code | [1..1] (CD-CHAR(2))UB-04 | |||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
admsrc | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 14 | reference supportinginfo.sequence rule | ||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 14 | value = 'admtype' | ||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 14 | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 14 | Claim inpatient admission type code | [1.1] (CD-CHAR(2)) | coding.system = url of code
system coding.code = the code value |
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admtype | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 14 | Claim inpatient admission type code | [1.1] (CD-CHAR(2)) | |||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
admtype | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 117 | reference supportinginfo.sequence rule | ||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 117 | value = 'discharge-status' | ||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 117 | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 117 | Patient discharge status code | [1.1] (CD-CHAR(2)) | coding.system = url of code
system coding.code = the code value |
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discharge-status | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 117 | Patient discharge status code | [1.1] (CD-CHAR(2)) | UB04 (Form Locator 17) | ||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
discharge-status | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 33, 32, 113 | reference supportinginfo.sequence rule | ||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 33, 32, 113 | value = 'DRG' | ||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 33, 32, 113 | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | code | 1..1 | CodeableConcept | Classification of the supplied information | 33, 32, 113 | Claim diagnosis related group (DRG), including the code system, the DRG version and the code value | [1..1] (CD-CHAR(4))DRG2 | coding.system = url of the code
system coding.version = DRG Version Code coding.code = the code value; e.g. '090' coding.display = concept associated with the code; e.g. 'CONCUSSION WITHOUT CC/MCC' |
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DRG | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 33, 32, 113 | [1..1] (CD-CHAR(4))DRG3 | ||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
DRG | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 46 | reference supportinginfo.sequence rule | ||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 46 | value = 'Place of Service' | ||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | 46 | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | code | 1..1 | CodeableConcept | Type of information | 46 | Place of service code | [1..1] (CD-CHAR(2)) | coding.system = url of the code
system coding.code = the code value |
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PlaceOfService | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 46 | Place of service code | [1..1] (CD-CHAR(2)) | |||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||||||||||
PlaceOfService | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | ||||||||||||||||||
ExplanationOfBenefit | diagnosis | sequence | 1..1 | positiveInt | Diagnosis instance identifier | New | reference diagnosis.sequence rule | |||||||||||||||
ExplanationOfBenefit | diagnosis | diagnosis | 1..1 | CodeableConcept | Nature of illness or problem | 6, 7, 8, 21, 22, 23, 30, 31, 145 | Diagnosis Code, Description | [1..1] (CD-ICD-9) or (CD-ICD-10) | coding.code = the code
value i.e. example 250.02 for ICD-9 i.e. example E11.65 for ICD-10 coding.system = url of code system i.e. example ICD-9 / ICD-10 text = string representation of the diagnosis |
CPCDS does not include MapID #31, Patient Reason for Visit Code | ||||||||||||
ExplanationOfBenefit | diagnosis | diagnosis | 1..1 | ICD-10 Codes (Example) | 6, 7, 8, 21, 22, 23, 30, 31, 145 | Diagnosis code | [1..1] (CD-ICD-9) or (CD-ICD-10) | ICD-9 or ICD-10 (Required) |
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ExplanationOfBenefit | diagnosis | diagnosis | Reference(Condition) | |||||||||||||||||||
ExplanationOfBenefit | diagnosis | type | 1..1 | CodeableConcept | Timing or nature of the diagnosis | New (6, 7, 8, 21, 22, 23, 30, 31) | [1..1] (CD) | |||||||||||||||
ExplanationOfBenefit | diagnosis | type | Example Diagnosis Type Codes (Example) | New (6, 7, 8, 21, 22, 23, 30, 31) | [1..1] (CD) | Diagnosis Type principal | secondary | patient reason for visit | external cause of injury |
Create a value set with these four concepts from SNOMED CT system | |||||||||||||||
ExplanationOfBenefit | diagnosis | onAdmission | 0..1 | CodeableConcept | Present on admission | 28, 29 | Present on admission | [1..1] CHAR ( 1 ) | coding.system = url of the code
system coding.code = the code value |
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ExplanationOfBenefit | diagnosis | onAdmission | Example Diagnosis on Admission Codes (Example) | 28, 29 | Present on admission | [1..1] CHAR ( 1 ) | ||||||||||||||||
ExplanationOfBenefit | diagnosis | packageCode | 0..1 | CodeableConcept | Package billing code | |||||||||||||||||
ExplanationOfBenefit | diagnosis | packageCode | Example Diagnosis Related Group Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | procedure | 0..* | BackboneElement | Clinical procedures performed | ||||||||||||||||||
ExplanationOfBenefit | procedure | sequence | 1..1 | positiveInt | Procedure instance identifier | New (9, 11, 24, 26) |
reference procedure.sequence rule | |||||||||||||||
ExplanationOfBenefit | procedure | type | 0..* | CodeableConcept | Category of Procedure | New (9, 11, 24, 26) |
principal | secondary1-24 |
Procedure Type | ||||||||||||||
ExplanationOfBenefit | procedure | type | Example Procedure Type Codes (Example) | New (9, 11, 24, 26) |
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ExplanationOfBenefit | procedure | date | 0..1 | dateTime | When the procedure was performed | 10,12, 25, 27 | Procedure date | [1..1] (TS8) | ||||||||||||||
ExplanationOfBenefit | procedure | procedure | 1..1 | Specific clinical procedure | 9, 11, 24, 26, 146 | ICD Procedure Code | [1..1] (CD) (CD-ICD-9) or (CD-ICD-10) | coding.code = the code
value text = string representation of the procedure |
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ExplanationOfBenefit | procedure | procedure | ICD-10 Procedure Codes (Example) | 9, 11, 24, 26, 146 | ICD Procedure Code | [1..1] (CD) (CD-ICD-9) or (CD-ICD-10) | coding.system = url of code system |
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ExplanationOfBenefit | procedure | procedure | procedureCodeableConcept | CodeableConcept | ICD-10 Procedure Codes (Example) | 9, 11, 24, 26 | ICD Procedure Code | [1..1] (CD) (CD-ICD-9) or (CD-ICD-10) | coding.system = url of code system |
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ExplanationOfBenefit | procedure | procedure | procedureReference--> | Reference(Procedure) | ||||||||||||||||||
ExplanationOfBenefit | procedure | udi | 0..* | Reference(Device) | Unique device identifier | |||||||||||||||||
ExplanationOfBenefit | precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | ||||||||||||||||||
ExplanationOfBenefit | insurance | Σ | 1..1 | BackboneElement | Patient insurance information | |||||||||||||||||
ExplanationOfBenefit | insurance | focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | New | value = true | ||||||||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | Ref (3) | Contained | ||||||||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | Ref (2) | Claim payer Identifier | Coverage.payer--> Organization.identifier | Contained (The Plan Organization who provides the coverage). Same value as ExplanationOfBenefit.insurer | ||||||||||||
ExplanationOfBenefit | insurance | preAuthRef | 0..* | string | Prior authorization reference number | |||||||||||||||||
ExplanationOfBenefit | insurance | Σ | 0..1 | BackboneElement | Patient insurance information | |||||||||||||||||
ExplanationOfBenefit | insurance | focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | New | value = false | ||||||||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | Ref (3) | Contained | ||||||||||||||
ExplanationOfBenefit | insurance | coverage--> | Σ | 1..1 | Reference(Coverage) | Insurance information | Ref (2) Ref (140) |
Claim primary payer identifier | Coverage.payer--> Organization.identifier | Contained (The Plan Organization who provides the coverage). Same value as ExplanationOfBenefit.insurer | ||||||||||||
ExplanationOfBenefit | insurance | preAuthRef | 0..* | string | Prior authorization reference number | |||||||||||||||||
ExplanationOfBenefit | accident | 0..1 | BackboneElement | Details of the event | ||||||||||||||||||
ExplanationOfBenefit | accident | date | 0..1 | date | When the incident occurred | |||||||||||||||||
ExplanationOfBenefit | accident | type | 0..1 | CodeableConcept | The nature of the accident | |||||||||||||||||
ExplanationOfBenefit | accident | type | V3 Value SetActIncidentCode (Extensible) | |||||||||||||||||||
ExplanationOfBenefit | accident | location | 0..1 | Where the event occurred | ||||||||||||||||||
ExplanationOfBenefit | accident | location | locationAddress | Address | ||||||||||||||||||
ExplanationOfBenefit | accident | location | locationReference | Reference(Location) | ||||||||||||||||||
ExplanationOfBenefit | item | 0..* | BackboneElement | Product or service provided | ||||||||||||||||||
ExplanationOfBenefit | item | sequence | 1..1 | positiveInt | Item instance identifier | 36 | Line number | |||||||||||||||
ExplanationOfBenefit | item | careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||||||||||||||
ExplanationOfBenefit | item | diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||||||||||||||
ExplanationOfBenefit | item | procedureSequence | 0..* | positiveInt | Applicable procedures | |||||||||||||||||
ExplanationOfBenefit | item | informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||||||||||||||
ExplanationOfBenefit | item | revenue | 1..1 | CodeableConcept | Revenue or cost center code | 86 | Revenue center code | [1..1] (CD-CHAR(4)) UB-04 | coding.system = url of code
system coding.code = the code value |
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ExplanationOfBenefit | item | revenue | Example Revenue Center Codes (Example) | 86 | Revenue center code | [1..1] (CD-CHAR(4)) UB-04 | ||||||||||||||||
ExplanationOfBenefit | item | category | 0..1 | CodeableConcept | Benefit classification | |||||||||||||||||
ExplanationOfBenefit | item | category | Benefit Category Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | define default value (Lisa to recommend) | ||||||||||||||||
ExplanationOfBenefit | item | productOrService | USCLS Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | modifier | 0..* | CodeableConcept | Product or service billing modifiers | |||||||||||||||||
ExplanationOfBenefit | item | modifier | Modifier type Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||||||||||||
ExplanationOfBenefit | item | programCode | Example Program Reason Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | serviced | 0..1 | Date or dates of service or product delivery | ||||||||||||||||||
ExplanationOfBenefit | item | serviced | servicedDate | date | ||||||||||||||||||
ExplanationOfBenefit | item | serviced | servicedPeriod | Period | ||||||||||||||||||
ExplanationOfBenefit | item | location | 0..1 | Place of service or where product was supplied | ||||||||||||||||||
ExplanationOfBenefit | item | location | Example Service Place Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | location | locationCodeableConcept | CodeableConcept | ||||||||||||||||||
ExplanationOfBenefit | item | location | locationAddress | Address | ||||||||||||||||||
ExplanationOfBenefit | item | location | locationReference--> | Reference(Location) | ||||||||||||||||||
ExplanationOfBenefit | item | quantity | 0..1 | SimpleQuantity | Count of products or services | 42 | Number of units | 1..1] NUMERIC (S7.3) |
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ExplanationOfBenefit | item | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||||||||||
ExplanationOfBenefit | item | factor | 0..1 | decimal | Price scaling factor | |||||||||||||||||
ExplanationOfBenefit | item | net | 0..1 | Money | Total item cost | |||||||||||||||||
ExplanationOfBenefit | item | udi--> | 0..* | Reference(Device) | Unique device identifier | |||||||||||||||||
ExplanationOfBenefit | item | bodySite | 0..1 | CodeableConcept | Anatomical location | |||||||||||||||||
ExplanationOfBenefit | item | bodySite | Oral Site Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | subSite | 0..* | CodeableConcept | Anatomical sub-location | |||||||||||||||||
ExplanationOfBenefit | item | subSite | Surface Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | item | encounter--> | 0..* | Reference(Encounter) | Encounters related to this billed item | |||||||||||||||||
ExplanationOfBenefit | item | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | 1..* | BackboneElement | Adjudication details | ||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | New (20) | ||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | category | Adjudication Value Codes (Example) | New (20) | values: submitted | allowed | deductible |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability | |||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | |||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | reason | Adjudication Reason Codes (Example) | |||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | amount | 0..1 | Money | Monetary amount | 20 | Amounts | NUMERIC ( S8.2 (11)) | May be populated | |||||||||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | value | 0..1 | decimal | Non-monitary value | |||||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | 0..* | BackboneElement | Adjudication details | ||||||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | 92 | Claim Payment Denial Code | |||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | category | Adjudication Value Codes (Example) | 92 | Claim Payment Denial Code | values: denialreason | ||||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | 92 | Claim Payment Denial Code | [0..1] (CD) | coding.system = url of code
system coding.code = the code value |
Claim Adjustment Reason Code (CARC) codes shall be used; optionally allow the Remittance Advice Remark Codes (RARCs) | ||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | reason | Adjudication Reason Codes (Example) | 92 | Claim Payment Denial Code | [0..1] (CD) | ||||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | amount | 0..1 | Money | Monetary amount | |||||||||||||||
denialreason | ExplanationOfBenefit | item | adjudication | value | 0..1 | decimal | Non-monitary value | |||||||||||||||
ExplanationOfBenefit | item | detail | value | 0..* | BackboneElement | Additional items | ||||||||||||||||
ExplanationOfBenefit | item | detail | sequence | 1..1 | positiveInt | Product or service provided | ||||||||||||||||
ExplanationOfBenefit | item | detail | revenue | 0..1 | CodeableConcept | Revenue or cost center code | ||||||||||||||||
ExplanationOfBenefit | item | detail | revenue | Example Revenue Center Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | item | detail | category | 0..1 | CodeableConcept | Benefit classification | ||||||||||||||||
ExplanationOfBenefit | item | detail | category | Benefit Category Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | item | detail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | ||||||||||||||||
ExplanationOfBenefit | item | detail | productOrService | USCLS Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | item | detail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | ||||||||||||||||
ExplanationOfBenefit | item | detail | modifier | Modifier type Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | item | detail | programCode | 0..* | CodeableConcept | Program the product or service is provided under | ||||||||||||||||
ExplanationOfBenefit | item | detail | programCode | Example Program Reason Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | item | detail | quantity | 0..1 | SimpleQuantity | Count of products or services | ||||||||||||||||
ExplanationOfBenefit | item | detail | unitPrice | 0..1 | Money | Fee, charge or cost per item | ||||||||||||||||
ExplanationOfBenefit | item | detail | factor | 0..1 | decimal | Price scaling factor | ||||||||||||||||
ExplanationOfBenefit | item | detail | net | 0..1 | Money | Total item cost | ||||||||||||||||
ExplanationOfBenefit | item | detail | udi--> | 0..* | Reference(Device) | Unique device identifier | ||||||||||||||||
ExplanationOfBenefit | item | detail | noteNumber | 0..* | positiveInt | Applicable note numbers | ||||||||||||||||
ExplanationOfBenefit | item | detail | adjudication | 0..* | see adjudication | Detail level adjudication details | ||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | 0..* | BackboneElement | Additional items | ||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | sequence | 1..1 | positiveInt | Product or service provided | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | revenue | 0..1 | CodeableConcept | Revenue or cost center code | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | revenue | Example Revenue Center Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | category | 0..1 | CodeableConcept | Benefit classification | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | category | Benefit Category Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | productOrService | USCLS Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | modifier | Modifier type Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | programCode | Example Program Reason Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | factor | 0..1 | decimal | Price scaling factor | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | net | 0..1 | Money | Total item cost | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | udi | 0..* | Reference(Device) | Unique device identifier | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | note | 0..* | positiveInt | Applicable note numbers | |||||||||||||||
ExplanationOfBenefit | item | detail | subDetail | adjudication | 0..* | see adjudication | Subdetail level adjudication details | |||||||||||||||
ExplanationOfBenefit | additem | 0..* | BackboneElement | Insurer added line items | ||||||||||||||||||
ExplanationOfBenefit | additem | itemSequence | 0..* | positiveInt | Item sequence number | |||||||||||||||||
ExplanationOfBenefit | additem | detailSequence | 0..* | positiveInt | Detail sequence number | |||||||||||||||||
ExplanationOfBenefit | additem | subDetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||||||||||||||
ExplanationOfBenefit | additem | provider--> | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||||||||||||||
ExplanationOfBenefit | additem | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||||||||||||
ExplanationOfBenefit | additem | productOrService | USCLS Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||||||||||||
ExplanationOfBenefit | additem | modifier | Modifier type Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | programCode | 0..* | CodeableConcept | Program the product or service is provided under | |||||||||||||||||
ExplanationOfBenefit | additem | programCode | Example Program Reason Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||||||||||||||
ExplanationOfBenefit | additem | serviced[x] | servicedDate | date | ||||||||||||||||||
ExplanationOfBenefit | additem | serviced[x] | servicedPeriod | Period | ||||||||||||||||||
ExplanationOfBenefit | additem | location[x] | 0..1 | Place of service or where product was supplied | ||||||||||||||||||
ExplanationOfBenefit | additem | location[x] | Example Service Place Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | location[x] | locationCodeableConcept | CodeableConcept | ||||||||||||||||||
ExplanationOfBenefit | additem | location[x] | locationAddress | Address | ||||||||||||||||||
ExplanationOfBenefit | additem | location[x] | locationReference--> | Reference(Location) | ||||||||||||||||||
ExplanationOfBenefit | additem | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||||||||||||
ExplanationOfBenefit | additem | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||||||||||
ExplanationOfBenefit | additem | factor | 0..1 | decimal | Price scaling factor | |||||||||||||||||
ExplanationOfBenefit | additem | net | 0..1 | Money | Total item cost | |||||||||||||||||
ExplanationOfBenefit | additem | bodySite | 0..1 | CodeableConcept | Anatomical location | |||||||||||||||||
ExplanationOfBenefit | additem | bodySite | Oral Site Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | subSite | 0..* | CodeableConcept | Anatomical sub-location | |||||||||||||||||
ExplanationOfBenefit | additem | subSite | Surface Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | additem | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||||||||||||
ExplanationOfBenefit | additem | adjudication | 0..* | see adjudication | Added items adjudication | |||||||||||||||||
ExplanationOfBenefit | additem | detail | 0..* | BackboneElement | Insurer added line items | |||||||||||||||||
ExplanationOfBenefit | additem | detail | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | ||||||||||||||||
ExplanationOfBenefit | additem | detail | productOrService | USCLS Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | additem | detail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | ||||||||||||||||
ExplanationOfBenefit | additem | detail | modifier | Modifier type Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | additem | detail | quantity | 0..1 | SimpleQuantity | Count of products or services | ||||||||||||||||
ExplanationOfBenefit | additem | detail | unitPrice | 0..1 | Money | Fee, charge or cost per item | ||||||||||||||||
ExplanationOfBenefit | additem | detail | factor | 0..1 | decimal | Price scaling factor | ||||||||||||||||
ExplanationOfBenefit | additem | detail | net | 0..1 | Money | Total item cost | ||||||||||||||||
ExplanationOfBenefit | additem | detail | noteNumber | 0..* | positiveInt | Applicable note numbers | ||||||||||||||||
ExplanationOfBenefit | additem | detail | adjudication | 0..* | see adjudication | Added items adjudication | ||||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | 0..* | BackboneElement | Insurer added line items | ||||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | ProductOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | ProductOrService | USCLS Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | modifier | 0..* | CodeableConcept | Service/Product billing modifiers | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | modifier | Modifier type Codes (Example) | |||||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | quantity | 0..1 | SimpleQuantity | Count of products or services | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | factor | 0..1 | decimal | Price scaling factor | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | net | 0..1 | Money | Total item cost | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | noteNumber | 0..* | positiveInt | Applicable note numbers | |||||||||||||||
ExplanationOfBenefit | additem | detail | subDetail | adjudication | 0..* | see adjudication | Added items adjudication | |||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | 1..* | BackboneElement | Header-level adjudication | |||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | New (20) | |||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | category | Adjudication Value Codes (Example) | New (20) | values: submitted | allowed | deductible |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability | ||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | ||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | reason | Adjudication Reason Codes (Example) | ||||||||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | amount | 0..1 | Money | Monetary amount | 20 | Amounts | NUMERIC ( S8.2 (11)) | |||||||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | value | 0..1 | decimal | Non-monitary value | ||||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | 1..1 | BackboneElement | Header-level adjudication | |||||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | 142 | Line benefit payment status | ||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | category | Adjudication Value Codes (Example) | 142 | Line benefit payment status | values: in network | out of network | other | |||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | ||||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | reason | Adjudication Reason Codes (Example) | ||||||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | amount | 0..1 | Money | Monetary amount | ||||||||||||||||
inoutnetwork | ExplanationOfBenefit | adjudication | value | 0..1 | decimal | Non-monitary value | ||||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | 0..* | BackboneElement | Header-level adjudication | |||||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | 92 | Claim Payment Denial Code | ||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | category | Adjudication Value Codes (Example) | 92 | Claim Payment Denial Code | values: denialreason | |||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | 92 | Claim Payment Denial Code | [0..1] (CD) | coding.system = url of code system co |
Claim Adjustment Reason Code (CARC) codes shall be used; optionally allow the Remittance Advice Remark Codes (RARCs) | |||||||||||
denialreason | ExplanationOfBenefit | adjudication | reason | Adjudication Reason Codes (Example | 92 | Claim Payment Denial Code | [0..1] (CD) | |||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | amount | 0..1 | Money | Monetary amount | ||||||||||||||||
denialreason | ExplanationOfBenefit | adjudication | value | 0..1 | decimal | Non-monitary value | ||||||||||||||||
ExplanationOfBenefit | total | Σ | 1..* | BackboneElement | Adjudication totals | 148 | [1..12] | |||||||||||||||
ExplanationOfBenefit | total | category | Σ | 1..1 | CodeableConcept | Type of adjudication information | New (148) | [1..1] (CD) | ||||||||||||||
ExplanationOfBenefit | total | category | Adjudication Value Codes (Example) | New (148) | values: submitted | allowed | deductible |coins | copay | disallowed |priorpayerpaid | payment | paidbypatient | paidtoprovider | paidtopatient | memberliability | |||||||||||||||||
ExplanationOfBenefit | total | amount | Σ | 1..1 | Money | Financial total for the category | 148 | Total Amount | [1..1]NUMERIC ( S8.2 (11)) | |||||||||||||
ExplanationOfBenefit | payment | 0..1 | BackboneElement | Payment Details | ||||||||||||||||||
ExplanationOfBenefit | payment | type | 0..1 | CodeableConcept | Partial or complete payment | 91 | Claim payment status code | [1..1] (CD) | coding.system = url of code
system coding.code = the code value |
|||||||||||||
ExplanationOfBenefit | payment | type | Example Payment Type Codes (Example) | 91 | Claim payment status code | [1..1] (CD) | ||||||||||||||||
ExplanationOfBenefit | payment | adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||||||||||||||
ExplanationOfBenefit | payment | adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance | 92 | Claim Payment Denial Code | [0..1] (CD) | coding.system = url of code
system coding.code = the code value |
Claim Adjustment Reason Code (CARC) codes shall be used; optionally allow the Remittance Advice Remark Codes (RARCs) | ||||||||||||
ExplanationOfBenefit | payment | adjustmentReason | Payment Adjustment Reason Codes (Example) | 92 | Claim Payment Denial Code | [0..1] (CD) | ||||||||||||||||
ExplanationOfBenefit | payment | date | 0..1 | date | Expected date of payment | 107 | Claim paid date | [1..1] (TS8) | ||||||||||||||
ExplanationOfBenefit | payment | amount | 0..1 | Money | Payable amount after adjustment | |||||||||||||||||
ExplanationOfBenefit | payment | identifier | 0..1 | Identifier | Business identifier for the payment | |||||||||||||||||
ExplanationOfBenefit | formCode | 0..1 | CodeableConcept | Printed form identifier | ||||||||||||||||||
ExplanationOfBenefit | formCode | Forms (Example) | ||||||||||||||||||||
ExplanationOfBenefit | form | 0..1 | Attachment | Printed reference or actual form | ||||||||||||||||||
ExplanationOfBenefit | processNote | 0..* | BackboneElement | Note concerning adjudication | ||||||||||||||||||
ExplanationOfBenefit | processNote | number | 0..1 | positiveInt | Note instance identifier | |||||||||||||||||
ExplanationOfBenefit | processNote | type | 0..1 | code | display | print | printoper | |||||||||||||||||
ExplanationOfBenefit | processNote | type | NoteType (Required) | |||||||||||||||||||
ExplanationOfBenefit | processNote | text | 0..1 | string | Note explanatory text | |||||||||||||||||
ExplanationOfBenefit | processNote | language | 0..1 | CodeableConcept | Language of the text | |||||||||||||||||
ExplanationOfBenefit | processNote | language | Common Languages (Preferred but limited to AllLanguages) | |||||||||||||||||||
ExplanationOfBenefit | benefitPeriod | 0..1 | Period | When the benefits are applicable | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | category | 1..1 | CodeableConcept | Benefit classification | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | category | Benefit Category Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | benefitBalance | excluded | 0..1 | boolean | Excluded from the plan | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | name | 0..1 | string | Short name for the benefit | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | description | 0..1 | string | Description of the benefit or services covered | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | network | 0..1 | CodeableConcept | In or out of network | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | network | Network Type Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | benefitBalance | unit | 0..1 | CodeableConcept | Individual or family | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | unit | Unit Type Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | benefitBalance | term | 0..1 | CodeableConcept | Annual or lifetime | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | term | Benefit Term Codes (Example) | |||||||||||||||||||
ExplanationOfBenefit | benefitBalance | financial | 0..* | BackboneElement | Benefit Summary | |||||||||||||||||
ExplanationOfBenefit | benefitBalance | financial | type | 1..1 | CodeableConcept | Benefit classification | ||||||||||||||||
ExplanationOfBenefit | benefitBalance | financial | type | Benefit Type Codes (Example) | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | allowed | 0..1 | Benefits allowed | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedUnsignedInt | unsignedInt | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedString | string | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | allowed | allowedMoney | Money | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | used | 0..1 | Benefits used | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | used | usedUnsignedInt | unsignedInt | ||||||||||||||||||
ExplanationOfBenefit | benefitBalance | used | usedMoney | Money |