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 Pharmacy mapping
[Previous Page](undefined)Slice | L0 | L1 | L2 | L3 | L4 | Flag | Cardinalityy | 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 | RX service reference
number |
||||||||
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) | New | |||||||||||
ExplanationOfBenefit | type | Σ | 1..1 | CodeableConcept | Category or discipline | 16 | Claim type | values: Pharmacy | ||||||
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: Pharmacy | 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 | Contained | ||||||
ExplanationOfBenefit | billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | |||||||||
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 (5) | Claim payer Identifier | Organization.identifier | Same as insurance.coverage.organization. Party responsible for reimbursing the provider. | |||||
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 | ||||||||||||
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 |
||||||||
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 |
|||||||||
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 (95, 96, 122) | Provider NPIs | [1..1] CHAR(10) | PractionerRole.practioner --> Practioner.identifier | PractionerRole.code = pcp | prescribing | ||||
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 | value = 1 | ||||||
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) | ||||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
claimrecvddate | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 88 | value = 1 | ||||||
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) | ||||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 77 | value = 1 | ||||||
dayssupply | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 77 | value = 'dayssupply' | ||||||
dayssupply | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | ||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | ||||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | 77 | Days supply | [1..1] NUMERIC (S3.0) | value=positive integer defined by Regex(0|[1-9][0-9]*), unit="d" | |||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
dayssupply | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
dawcode | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 79 | value = 1 | ||||||
dawcode | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 79 | value = 'dawcode' | ||||||
dawcode | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
dawcode | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 79 | DAW product selection code | [1..1] CHAR(2) Industry standard code |
Value set is in ResDAC |
||||
dawcode | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 79 | NCPDP field # 408-D8 (Dispensed As Written (DAW)/Product Selection Code) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200387000&system=sdo | ||||||||
dawcode | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
dawcode | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
dawcode | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
refillnum | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 137 | reference supportinginfo.sequence rule | ||||||
refillnum | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 137 | value = 'refillnum' | ||||||
refillnum | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
refillnum | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | ||||||||
refillnum | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | ||||||||||
refillnum | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | 137 | Refill number | [1..1] NUMERIC (S3.0) | value=positive integer defined by Regex(0|[1-9][0-9]*), unit="d" | |||||
refillnum | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
refillnum | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
refillnum | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 143 | reference supportinginfo.sequence rule | ||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 143 | value = 'rxorigincode' | ||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 143 | Prescription origin code | ||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | 143 | NCPDP field # 419-DJ (Prescription Origin Code) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200387000&system=sdo | ||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
rxorigincode | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 144 | reference supportinginfo.sequence rule | ||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 144 | value = 'brandgeneric' | ||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 144 | Plan reported brand-generic code | [1..1] CHAR(1) Industry standard code |
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brandgeneric | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | NCPDP field # 686 (Brand/Generic Indicator) https://ushik.ahrq.gov/ViewItemDetails?itemKey=200197000&system=sdo | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
brandgeneric | ExplanationOfBenefit | supportingInfo | 1..1 | BackboneElement | Supporting information | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | sequence | 1..1 | positiveInt | Information instance identifier | 80 | reference supportinginfo.sequence rule | ||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | category | 1..1 | CodeableConcept | Classification of the supplied information | 80 | value = 'dispensingstatus' | ||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | category | Claim Information Category Codes (Example) | ||||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | code | 0..1 | CodeableConcept | Type of information | 80 | [1..1] CHAR(1) Industry standard code |
||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | code | Exception Codes (Example) | NCPDP field # 343-HD (Dispensing Status) https://ushik.ahrq.gov/ViewItemDetails?system=mdr&itemKey=60594000 | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | timing | 0..1 | When it occurred | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | timing | timingDate | date | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | timing | timingPeriod | Period | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | 0..1 | Data to be provided | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | valueBoolean | boolean | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | valueString | string | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | valueQuantity | Quantity | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | valueAttachment | Attachment | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | value | valueReference--> | Reference(Any) | |||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | reason | 0..1 | Coding | Explanation for the information | ||||||||
dispensingstatus | ExplanationOfBenefit | supportingInfo | reason | Missing Tooth Reason Codes (Example) | ||||||||||
ExplanationOfBenefit | diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | ||||||||||
ExplanationOfBenefit | diagnosis | sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||||||
ExplanationOfBenefit | diagnosis | diagnosis | 1..1 | CodeableConcept | Nature of illness or problem | |||||||||
ExplanationOfBenefit | diagnosis | diagnosis | ICD-10 Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | diagnosis | Reference(Condition) | |||||||||||
ExplanationOfBenefit | diagnosis | type | 0..* | CodeableConcept | Timing or nature of the diagnosis | |||||||||
ExplanationOfBenefit | diagnosis | type | Example Diagnosis Type Codes (Example) | |||||||||||
ExplanationOfBenefit | diagnosis | onAdmission | 0..1 | CodeableConcept | Present on admission | |||||||||
ExplanationOfBenefit | diagnosis | onAdmission | Example Diagnosis on Admission Codes (Example) | |||||||||||
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 | |||||||||
ExplanationOfBenefit | procedure | type | 0..* | CodeableConcept | Category of Procedure | |||||||||
ExplanationOfBenefit | procedure | type | Example Procedure Type Codes (Example) | |||||||||||
ExplanationOfBenefit | procedure | date | 0..1 | dateTime | When the procedure was performed | |||||||||
ExplanationOfBenefit | procedure | procedure | 1..1 | Specific clinical procedure | ||||||||||
ExplanationOfBenefit | procedure | procedure | ICD-10 Procedure Codes (Example) | |||||||||||
ExplanationOfBenefit | procedure | procedure | procedureCodeableConcept | CodeableConcept | ||||||||||
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) | |||||||
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 | INT |
||||||
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 | 0..1 | CodeableConcept | Revenue or cost center code | |||||||||
ExplanationOfBenefit | item | revenue | Example Revenue Center Codes (Example) | |||||||||||
ExplanationOfBenefit | item | category | 0..1 | CodeableConcept | Benefit classification | 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 | ||||
ExplanationOfBenefit | item | category | Benefit Category Codes (Example) | 34 | Type of service | [1.1] (CD-CHAR(5)) | ||||||||
ExplanationOfBenefit | item | productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code | 38, 78 | National drug code Compound Code |
[1..1] CHAR(11) Industry standard code |
||||||
ExplanationOfBenefit | item | productOrService | USCLS Codes (Example) | 38, 78 | [1..1] CHAR(11) Industry standard code |
Value set will be NDC Codes when
Compound Code = 0 or 1. When the
Compound Code = 2, productOrService = "compound" When the Compound Code = 2, map the ingredient to ExplanationOfBenefit.item.detail.productOrService |
https://www.hl7.org/fhir/claim-example-pharmacy-compound.json.html |
|||||||
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 | Date or dates of service or product delivery | 90 | Service (from) date | [1..1] (TS8) | ||||||
ExplanationOfBenefit | item | serviced | servicedPeriod | Period | Date or dates of service or product delivery | |||||||||
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 | 39 | [1..1] NUMERIC (S7.3) |
We are going to look at the option to point to MedicationDispense Resource | ||||||
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)) | ||||
adjudicationamounttype | ExplanationOfBenefit | item | adjudication | value | 0..1 | decimal | Non-monitary value | |||||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | 1..1 | BackboneElement | Adjudication details | ||||||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | category | 1..1 | CodeableConcept | Type of adjudication information | 142 | Line benefit payment status | |||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | category | Adjudication Value Codes (Example) | 142 | Line benefit payment status | values: in network | out of network | other | ||||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | reason | 0..1 | CodeableConcept | Explanation of adjudication outcome | |||||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | reason | Adjudication Reason Codes (Example) | |||||||||
inoutnetwork | ExplanationOfBenefit | item | adjudication | amount | 0..1 | Money | Monetary amount | |||||||
inoutnetwork | 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 | 38 | National drug code | [1..1] CHAR(11) Industry standard code |
|||||
ExplanationOfBenefit | item | detail | productOrService | USCLS Codes (Example) | 38 | [1..1] CHAR(11) Ind |
When the Compound Code = 2, map the NDC as the ingredient | https://www.hl7.org/fhir/claim-example-pharmacy-compound.json.html |
||||||
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 | ||||||||
adjudicationamounttype | ExplanationOfBenefit | adjudication | category | Adjudication Value Codes (Example) | 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 | ||||||||
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 (Exampl | 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 | ||||||||
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) | What will this value set be? | |||||||
ExplanationOfBenefit | payment | adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||||||
ExplanationOfBenefit | payment | adjustmentReason | 0..1 | CodeableConcept | Explanation for the variance | |||||||||
ExplanationOfBenefit | payment | adjustmentReason | Payment Adjustment Reason Codes (Example) | |||||||||||
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 |